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Columbia  2Bnit)er^ft|) 

CoUegc  of  ^fjpsiiciansi  anti  burgeons; 
Hiiirarp 


IN-KNEE:   ITS   RELATION   TO   RICKETS, 


LONDON  : 

PRINTED    BY    WEST,    NEWMAN    AND  CO. 

HATTON    GARDEN,    E.C. 


MEDICAL  AND  SURGICAL  ASPECTS 


IN-KNEE    (GENU-VALGUM): 

ITS    RELATION    TO 

RICKETS, 

ITS 

PREVENTION  AND  ITS  TREATMENT  WITH  AND  WITHOUT 

SUEGIGAL   OPEEATION. 

BY 

W.   J.   LITTLE,   M. p.,   F.R.G.P., 

LATE    SENIOR   PHYSICIAN   TO   AND   LECTUKER   ON   MEDICINE   AT    THE   LONDON  HOSPITAL  ; 

VISITING   PHYSICIAN   TO   THE   INFANT   OKPHAN   ASYLUM  AT   -VVANSTEAD, 

THE   EAELSWOOD   ASYLUM   FOE  IDIOTS  ; 

FOUNDEK   OF   THE    KOYAL   OETHOPaiDIC   HOSPITAL  ;    ETC. 

ASSISTED    BY 

E.    MUIEHEAD    LITTLE,    M.E.C.S. 


Illustrated  by  upwards  of  Fifty  Figures  and  Diagrams. 


D.     APPLETON     &     CO.,      NEW     YOEK, 

1882. 
3i 


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ID 

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TO 

PROFESSOE    GROSS,    M.D.,    D.C.L., 

ETC.,    ETC., 

FATHER     OF     SURGEEY 

IN 

AMEEICA, 

AN    ENLIGHTENED    AND    HONOURABLE    EXAMPLE    OF    ALL    THAT 
IS    NOBLE    IN    OUR   PROFESSION, 

AND   TO   HIS 

MEDICAL     AND     SURGICAL     BRETHREN, 

IN 

GRATEFUL   ACKNOWLEDGMENT    OF   THEIR    CORDIAL   RECEPTION 

OF    HIM    WHEN    ON   A   VISIT    TO    THE    UNITED    STATES 

IN    1878, 

THIS   BOOK   IS   INSCRIBED 

BY      THE      AUTHOR. 


Digitized  by  the  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/medicalsurgicalaOOIitt 


CONTENTS. 


Aberration  of  form,  no,  without  alteration  of  structure 
Accident  may  cause  the  distortion      .         .         . 
Accommodative  changes     ....••• 
Activity,  intellectual,  of  parent,  in  excess,  a  cause     . 

,,         cerebro-spinal,         ,,  ,,  5?  •         • 

Adolescents,  tall,  often  become  affected  with  atonic  in-knee 
Adults,  curable  in,  without  operation  .         .         .         . 

Aitken,  Dr.,  on  undue  hairiness  in  rickets 
Animal  food,  aversion  to,  often  observed  in  atonic  distortions 

Annandale,  osteotomy  by 

Antiseptic  system,  Lister's,  available  in  osteotomy     . 

Arms,  the,  disproportionately  long  in  rickets      .         .         .         . 

Arthritis  deformans  and  rheumatic  in-knee         .         .         .         . 

Asphyxia  neonatorum,  in-knee  from 

Atalectasis  and  in-knee       .         .         ... 
Atonic  disorders,  increase  of,  through  civilisation 

„       in-knee  may  co- exist  with  atonic  in-ankle  and  atonic 

spinal  curvature 

,,       in-ankle  may  precede  in-knee  and  scoliosis     . 

,,       in-knee,  diagnosis  from  rickets        .         . 

,,  ,,        may  return  on  re -application  of  exciting  causes 

,,  „        occurs  mainly  at  the  two  most  rapid  periods  of 

growth 

,,  ,,        occurs  more  readily  in  tall  infants     . 

Atony  of  fibrous  tissues  a  stage  of  rickets  ?    _      . 

,,  ,,         structures,  cause  of  other  disorders 

Atrophy  of  external  condyle,  see  deficiency  of    . 

B. 


PAGE 

88 
8 
11 
69 
69 
19 
30 

.       107 

75 

148,  152 

.  152 
81 
59 
95 
10 
69 

70 

70 

26,  70 

78 

75,  88 
88 
41 
15 
19 


Baker,  H.  F 

Beaded  ribs  in  rickets  .         .         .         .         • 

Belly  very  protuberant,  in  rickety  cases 
Billroth  on  redressement  force    .         .         .  • 

,,        ,,   statistics  of  osteotomy 
,,        ,,   supra-condylar  osteotomy 
Bloodless  method,  Esmarch's,  useful  in  osteotomy 
Bone,  simple  division  recommended  . 
,,      removal  of  portion  undesirable  _ 
,,  ,,  „        length  impaired 

„      bent,  lengthened  by  simple  division 


33 

80,  85 
81 
130 
142 
149 
154 
160 
160 
160 
160 


Vlll 


CONTENTS. 


Bones,  Macewen  on  cutting  the  comparatively  soft,  of  adole- 
scents 
.,      once  ebiii-uateil  after  rickets  do  not  again  soften  from 

that  disease 
may  they  soften  from  scorbutus  ? 
most  rapid  growth  in  lower  limbs  during  the  earliest 

months  of  life 
primitive  malformation  of,  eiToneous      .         .         .         . 
curvature  of,  may  take  place  after  subsidence  of  rickety 

disease 

„  from  gravity 

,,  ,,    scorbutus  ? 

,,  ,,    phthisis'? 

,,  ,,    atony  and  paralysis    . 

wasting  of,  Mikulicz  on   . 

,,  in  paralytic  in-knee 

density  of,  increased  in  rickets 
Bouvier  on  iu-knee,  as  the  first  stage  of  rickets 
Bow-legged  knee  curvature         .... 

Brain,  excess  of  stimulating  amusements  and  pursuits  favours 

distortion 
Breast-milk,  absence  of       .......         . 

Broca,  views  on  rickets        ........ 

Brown,  Dr.  Buckminster,  on  mechanical  treatment 

Burdach 


143 
79 


16,83 
150 


18 
79 


93 
57 

57 
57 
31 
18 

68 
37 
89 
133 
16 


Cartilages  thickened  by  undue  pressure 
,,  thinned  by  diminished  pressure 

,,  C.  Reyher  on     . 

CerelDro-spinal  system,  influence  on  in-knee 
Changes,  the  mechanical,  similar  in  all  forms 
Chest  flattened  and  narrowed  in  rickets 
Clavicles  arched  upwards  and  forwards  in  rickets 
Compression  of  limbs,  undue,  evils  of 
Condyle,  internal  enlarged,  not  a  primary  cause 
,,  ,,  ,,     pathognomonic 

,,        the  normal  length  of 
,,        prominent        .... 
external,  deficiency  of  primary  cause  .         .     19, 

,,  ,,  ))     a  more  common  marked  con- 

dition 

„  ,,  slight  deficiency  occasions  appreciable  dis- 

distortion 
Confinement,  long,  hurtful 
Congenital  in-knee      .... 
Constitutional  conditions  in  distortion 
Creases  in  rickety  thighs     . 
Crossed-legs  distortion 

,,  j)osition  aids  cure    . 

CruveiUiier,  J 

Curvature  of  bones  from  paralysis 

muscular  contraction 
rickets 


58 
58 
59 
65 
61 
81 
81 
114 
4 
66 

22,  25 
25 

58,  65 

19 

153 

151 

2 

21 

106 
1 

133 
43 
95 
66 
96 


CONTENTS. 


IX 


Curvature  of  bones  from  statical  inilueuce 
,,  ,,  ,,       innutrition,  atrophy 

,,  of  knee  outwards 

Curves,  successive,  in  scoliosis    . 
,,  ,,  rickety  limbs    . 

,,       explanation  of  production 
Cyanosis,  and  in-knee 

,,         Mikulicz  on,  as  a  cause  of  in-knee 


101 

12 

99 

100 

lO'J 

10,  61 

61 


D. 

Debility,  cause  of  in-knee  ...... 

Deficiency  of  external  condyle    .         ..        .         ... 

Density  of  bones  increased  in  rickets 
Diet,  a  too  watery,  a  cause  of  atonic  in-knee 
Digestion,  weak,  often  a  co-existent  atonic  ati'ection 
Disease,  any  of  knee,  may  cause  the  distortion 
Distortions,  rare  amongst  oriental  and  tropical  races 
Disuse,  persistent,  influence  of   . 

E. 

Eburnation  of  bones  froixi  rickets 

,,  density  of  bones  increased  in 

,,  none  in  "  mollities  ossium" 

Elasticity  of  structure 
Enamel  on  teeth,  want  of  in  rickets    . 
Epiphysis  of  tibia  and  fibula  in  rickets 
Esmarch,  bloodless  method  in  osteotomy 
Exercise  during  treatment 
Extremities,  the  lower,  most  visibly  affected  in  rickets 

„  ,,  development  of  them  in  rickets  more  or 

less  arrested 


2,  9 
19 
57 
66 
75 
2 
73 
20 


57 

57 

89 

145 

85 

84 

140 

123 

81 

82 


F. 

Fascia  lata,  its  action  in  bracing  the  knee           ....  53 

Fatigue  as  an  exciting  cause        .......  53 

Femoral  diaphysis,  changes  of,  in  in-knee           ....  53 

,,                 ,,          Linhart  on    .......  41 

„                  „          Mikulicz  on           ......  55 

,,                ,,         Macewen  on 41 

,,                 ,,          increased  growth           .....  136 

,,         epiphysis,  changes  of,  Mikulicz  on        ....  56 

Femur,  natural  adduction  of,  not  a  primary  cause     ...  4 

,,       and  tibia,  form  of,  may  aid  other  causes         ...  49 

Fevers  during  convalescence  cause  of  in-knee     .         .         .         .  2,  9 

Flat-foot,  co-existence  with  in-knee    ......  7 

Food,  animal,  aversion  to,  often  shown  by  atonic  subjects           .  75 
Foods,  unsuitable  articles  for  infants           .         .         .         .         .67 

Foot,  inversion  or  eversion  of,  in  in-knee   ....  99,  116 

G. 

Gap,  between  external  condyle  and  tibia    ....         27.  131 

,,      modes  of  filling  up      ......  29,  13o,  155 

,,      nature  can  fill  up  even  in  the  adult  .....         30 

h 


X  C0NTKNT8. 

PAGE 

Gait  in  iu-kiiee    ..........  7 

Gentle  means,  explanation  of  action 132 

Genu-varuna        ..........         13 

Genu- valgum  (see  in-knee). 

„  not  confined  to  rickets 2,  143 

Genu-valgns  talipes,  spui'ious,  with  in-knee        ....  7 

Genu-varus  talipes,         ,,  ,,  ,,....  7 

Genu,  extrorsuni  cui'vatum         .......         12 

Gravity,  influence  of  .         .         .         .  2,  8,  15,  36,  49,  65,  78,  188 

Gross,  Professor  .........       147 

Gx'owth,  two  fast  periods  of         .....         .  16,  19 

,,        explanation  of  rapidity  at  particular  periods         .  16,  87 

,,        inordinate  rapidity  of,  cause  of  distortion     .         .  10,  75 

,,        rapid  after  severe  illness,  need  of  rest  and  good  feeding         75 
,,        does  osteotomy  impair  it  ?    ......       158 

Guerin,  Jules,  experiments  on  large  subcutaneous  division  in 

animals  useful  to  men     19,  31,  33,  90 


H. 

Hand-feeding  of  infants  a  cause  of  atonic  in-knee 
Hairiness,  undue  in  rickets  ..... 

Hamstring  division     ....... 

Harrison     ......... 

Head  disposed  to  be  relatively  enlarged  in  rickets 

,,     may  be  one-fourth  the  length  of  the  body  in  rickets 
Height,  inordinate  cause  of  distortions 
Hips  and  knees  sometimes  contracted  at  birth    . 
Holden,  exaggerated  opinion  as  to  normal  length  of  external 

condyle 

Horse  exercise 

Hueter,  C. 

„  pathology  .... 

,,  treatment  of  in-knee  by  flexion 

Hutchinson,  on  rachitis       .... 
Hygiene,  neglect  of,  favours  production  of  in-knee 


66 

107 

127 

9 

81 

81 

3 

35 

22 

133 

7,  29 

40 
113 
131 

68 


I. 

Infancy,  earliest  period  of,  growth  most  rapid 

,,         rate  of  growth  during   . 
In-ankle,  with  in-knee 
In-knee,  adiilt,  cured  without  operation 

,,        definition  of  . 

,,        varieties  of    . 

,,        from  fatigue 

,,        infantile 

,,        idiopathic 

,,        adolescent 

,,        rachitic 

,,        statical 

,,        congenital 

,,        accommodative 

,,        paralytic 

,,        spasm  .... 

,,        atonic   .... 


16 
16 

7 

30 

1 

2 

18 

8,  12 

25 

8 

2,  7,  10 

2 

2,  5,  8 

10 

2,  92 

2,  10,  95 

8,  15,  19 


CONTENTS. 


XI 


In-knee,  strumous 

,,  rheumatic 

,,  from  inordinate  stoutness 

„  „             „          growth 

,,  disappearance  on  bending 

,,  fevers  from  debiHty,  after 

,,  never  a  normal  condition 

,,  influenced  by  normal  anatomic  conditions 

,,  frequency  of 

,,  traumatic 

,,  from  partial  luxation  of  epiphysis 

,,  with  scoliosis,  miscalled  "lateral  curvature 

„  outward  rotation  of  leg  in 

,,  with  flat-foot 

,,  ,,     ankylosis 

,,  from  carrying  heavy  weights 

,,  in  cyanosis  and  atelectasis 

,,  from  excessive  use         .  . 

,,  morbid  anatomy  . 

,,  pathology 

,,  prevention  of 

,,  from  curvature  of  tibia 

,,  non-i'achitic,  Dr.  Shaffer  on 

,,  hereditary  influence  in 

,,  cure  of,  by  deposit  of  bone  and  cartilage 
Intellectual  activity  of  parent  in  excess  a  cause 


of  spine 


PAGE 

3,  101 
3 
3 

2,  9,  15 

5,  56 

2,9 

3 

3,  19 

7 

8,  62 

8 

9 

6 

9 

101 

10 

10 

10 

14,  44 

14 

109,  139 

20 

32 

70 

51 

69 


Jenner,  Sir  W.,  on  the  rickety  skull  . 
Johnson,  Dr.       ....... 

Joints,  less  well-knit  in  some  families  and  races 
,,      constant  fixation  to  be  avoided 


104 
69 
72 

135 


K. 

Knee,  mechanically  altered  relations  in 

,,      hyper-extension  of    . 
Knee  joint,  opening  of,  for  in-knee 
Knock-knee,  symptoms  of  . 


21 

56 
149 

77 


Langenbeek        

Legs,  disproportionately  short  in  rickets     . 

Leg  bones,  curvature  of,  augments  apparent  in-knee 

Ligament,  internal  lateral  of  knee,  elongation  of 

,,  external         ,,  ,,       shortening  of 

,,  ,,        Linhart  on  . 

Limb,  the  soundest,  provided  only  with  a  maximum 
Linhart,  morbid  anatomy  ..... 

,,       on  instrumental  treatment    . 
Lister,  his  antiseptic  method  available  in  osteotomy 
Little,  Louis  Stromeyer      ..... 
Locomotion,  excess  of,  a  cause    .... 
Lordosis,  not  always  from  rickets 
Luxation  of  patella,  partial  or  complete 


.  19,3 
.  19,  3 

of  strength 


147 

81 

90 

i,  136 

i,  136 

39 

37 

39 

123 

140 

141 

69 

84 

60 


XII 


rONTKNTS. 


M. 

Macewen    ........ 

Miilfonnatiou,  primitive,  of  bones  theory  erroneous 
Manipulations,  mode  of  doin^^     .... 

Mayer,  H 

Mechanical  appliances  ..... 

,,  ,,  unsuitable  ones 

,,  treatment,  relapses  after 

^ilikulicz       ........ 

,,         on  wasting  of  bones       .... 

,,  ,,  cliaufjes  in  ligaments 

,,  ,,  increased  growth  of  femoral  diaphysis 

Microscopical  conditions      ..... 

Mikromele  ....... 

Milk,  fresh  or  unfresh,  important  difference  between 
"  Mollifies  ossium,"  nut  rickets  .... 

,,  ,,         is  incurable 

^forbid  anatomj',  obliqiiity  of  articular  surfacos 

,,  ,,  Sandifort  .... 

„  „  Mayer 

,,  ,,  Mikulicz  .... 

,,  ,,  Linhart   ..... 

Muscles,  structural  shortening  of         .         .         . 
Muscular  contraction  of  secondary  importance   . 


7,  20 


effects 


PAGE 

20 

wo 

115 

3B,  45 

IIG 

122 

139 

35 

57 

59 

13G 

21 

82 

C7 

89 

89 

35 

43 

46 

89 

11 

95 

60 


N. 

Natural  cure  by  deposit  of  new  bone  and  cartilage     ...  29 

Nervous  system,  disorder  of,  in  in-knee       .....  66 

Nodes  at  the  extremities  of  the  long  bones  in  rickets  .         .  89 

Nutrition  of  tissues,  insufficient  in  atonic  in-knee       ...  65 
,,         full,    necessary    during    convalescence    from    acute 

diseases  75 

O. 


Osteo-pliyt 

c  fcn-mations  in  in-knee      .... 

4 

i,  59 

.,             Mikulicz  on            ... 

. 

59 

,, 

,,             Sandifort  on          ... 

44 

Osteotome 

Macewen's         ...... 

. 

153 

Osteotomy 

Annandale         ...... 

148 

152 

Barwell     ....... 

152 

Macewen  on      .....         . 

45,  141 

154 

relapses  after    ...... 

142 

Macewen,  successes  in      . 

143 

necessity  after  puberty  in  severest  cases  . 

143 

chisel,  introduction  of,  in           ... 

143 

the  complement  to  instruments 

145 

W.  Adams  on    . 

147 

Barker  on          ...... 

148 

Barton  Rhea  on         ....         . 

147 

Grosse,  Professor  on           .... 

147 

Langenbeck  on           ..... 

147 

L.  Stromcyer  Little  on     . 

147 

Ogston  on 

. 

152 

CONTENTS. 


Xlll 


Osteotomy,  Reeves  on  .         .         . 

Rupra-condylar,  Bilrotli  on 

,,  ,,         Macewen's  mode  of  perfovmin 

effect  of  Macewen'fi  method 

subcutaneous,  first  performed 

unnecessary,  often  been  done 

simultaneously  in  both  le.sfs 

unnecessary  and  undesirable  in  young  children 
Out-ankle,  with  in-knee 
Out-knee  (genu-varum) 

,,        accommodative    . 
Over-rapid  growth 
Over-work  and  over-use 


U<) 

149,  155 

155 

.       149 

.       151 

.       151 

.       144 

7 

12,  74 

74 

15 

37 


P. 


Pancoast,  Dr.       ........ 

Paralysis,  infantile,  a  cause  of  in-knee 
Patella,  luxation  of,  partial  or  complete 

,,        ossification  of  .....         . 

,,        wearing  away  from  undue  pressure 

,,        Mikulicz  on    . 
Periods,  the  two  fast  growing,  of  life  a  cause  of  distortions 
Phokomelie  ........ 

Phthisis,  bones  wasted  in    . 
Position,  extended       . 

Pressure,  undue,  thickening  of  cartilages  from   . 
,,         absence  of,  thinning  of  cartilages  from 
Prevention  of  in-knee  ...... 

Progress,  rate  of,  with  mechanical  treatment 
Puberty,  rapid  growth  about       ..... 

R. 


60, 


15 


147 

10 

97,  145 

101 
59 
59 
19,  75 
82 
58 

133 
58 
59 

109 
124,  135 
16 


Races,  oriental,  joints  less  well-knit  than  in  robust  Europeans 
Rachitic  disease  exclusively  limited  to  early  childhood     18,  34 
Redressement  force      ........ 

Rest,  a  means  of  preventing  distortions  in  chilhood  after  severe 

illness 
Reyher,  C,  on  the  changes  in  unused  cartilage 
Rheumatic  in-knee  and  arthritis  deformans 

,,  extreme  in-knee         .... 

Rickets,  a  more  or  less  general  and  specific  disease 

,,       restricted  growth  during 

,,        period  of  its  occurrence 

,,        discussion  at  the  Pathological  Society  . 

,,        not  a  recurrent  disease 

.,        Guerin  on      .....         . 

,,        intra-uterine  ..... 

,,       increased  thickness  of  bones  in 

,,        eburnation      ...... 

,,        shortening      ...... 

,,       artificial  production  of  . 

,,        occurs  only  at  the  first  fast  growing  period  of  life 

,,        nodes  at  the  ends  of  the  long  bones,  in 

,,       curving  in  of  lower  third  of  femur 


72 

78,  89 

129 

75 
59 

59,  97 
64 
80 
19 
18 
18 
78 
34 

35,  82 
57 
57 
80 
83 
88 
89 
55 


XIV 


CONTENTS. 


PAGE 

Rickets,  many  foi-ms,  formerly  described    .....       101 

,,  ■     dependence  should  be  placed  on  more  than  one  sign  in       105 
,,       creases  in  limbs,  how  produced     .....       lOG 

,,        undue  hairiness  in  .......       107 

,,        coustitutioual  treatment         ......       Ill 

,,       mechanical  and  operative  treatment      ....       113 

Rickety  subjects  more  or  less  stunted          ....  19,  81 

,,  in-knee,  diagnosis  from  atonic  ....  20,  71,  88 
,,       head 81 

Rokitausky 43 

Rotation  outwards  of  tibia  as  a  cause  .....         52 


S. 

Sandifort,  morbid  anatomy 

Scarlet-fever,  weakness  and  convalescence  as  a  cause 

"  Schlottern,"  or  "  wobbling"  of  knee 

Schwartz     ......... 

Scissor-leg  distortion  ....... 

Scoliosis,  analogy  of,  with  atonic  in-knee  and  in-ankle 

,,         often  co-exists  at  puberty  with  atonic  in-knee 
Spasm,  infantile,  cause  of  in-knee 
Standing,  excess  of,  as  a  cause    . 
Statical  influence,  C.  Hueter  on 
Stoutness,  undue,  cause  of  in-knee 
Shaffer,  Dr.  N.  M.,  on  rachitic  form  . 

,,             ,,             ,,  value  of  gentle  means  of  cure 
Stromeyer,  Ernst 

,,  Louis         ..... 

Synovitis,  in-knee  from       .... 
Subluxation  of  tibia  with  in-knee 

T. 

Tailor's  occupation  favourable  to  cm-e 

Teeth,  condition  of,  in  rickets 

Thomas,  Dr.,  observations  on  fresh  and  unfresh  milk 

Tibia  often  most  affected  in  so-called  in-knee 

Toes,  the,  turning  in  or  out  in  in-knee 

Tone,  deficiency  of,  a  pathological  state 

Town,  life  of,  compared  with  country,  as  cause 

Treatment  ....... 

Trunk,  the,  relatively  long  in  rickets 


31,43 

9,  75 

27,  42 

16 

1 

99 

70 

2,  10 

69,  74 

51 

3 

32 

131 

15 

15 

11,63 

101 


.  13S 
85,  106 
67 
20 
99 
40 
68 
108 
86 


Vegetables,  green,  and  animal  food,  aversion  to  of  atonic  subjects  75 

A^ertebrte  comparatively  little  affected  in  congenital  rickets        .  83 

Violent  method  of  cure 129 

Volkmauu   .         .         .         .         .         .         .         .         .         ■         .  7,  18 

Von  Aramon  on  congenital  in-knee     ......  35 


W. 

Wasting  of  bones  in  phthisis 

Watery  diet,  cause  of  atonic  distortions 

Weber,  the  brothers    .... 


58 

66,  110 

38 


CONTENTS. 


XV 


Weights,  undue  carrying  of 
Will,  influence  of 
"  Wobbling  "  of  knee  . 
X-knee         .... 


PAGE 

79 

20 

27,  42,  132 

1 


LIST   OF  ILLUSTRATIONS. 

FIG. 

1.  Peculiar  crossed-leg  deformity      ......  1 

2.  Moderate  knock-  or  in-knee  (non-rachitic)    ....  4 

3.  Severe  neglected  knock-  or  in-knee  (non-rachitic)         .         .  5 

4.  Rachitic  in-kuees  .........  6 

5.  Atonic  in-knee       .........  9 

6.  Double  outward  curvature  of  lower  extremities    ...  13 

7.  Rachitic  in-knee  and  curvature  of  one  leg    ....  20 

8.  Drawing  of  average  femur,  with  a  femur  probably  rickety  .  23 

9.  Drawing  to  show  the  amount  required  to  rectify  the  greater 

length  of  internal  condyle         ......         23 

10.  Views  of  the  corresponding  leg  bones   .....         24 

11.  Moderate  atonic  in-knee,  to  show  the  prominence  of  internal 

condyle     ..........  25 

12.  Natural  contour  of  limbs  in  atonic  in-knee  ....  26 

13.  Morbid  anatomy,  view  of  in-knee,  from  Sandifort         .         .  44 

14.  The  same,  placed  by  us  in  the  proper  relation  to  exhibit  the 

same  gap,  shown  in  diagram  a         .....         44 

15.  Extreme  atonic  in-knee,  from  Mayer   .....         45 

16.  View  of  a  case  called  genu- valgum,  from  Mayer,  in  which 

the  principal  disorder  consisted  of  abduction  and  curvature 

of  the  tibia        .........         46 

17.  The  left  limb  from  the  same  patient  after  osteotomy,  which 

had  been  doubtless  more  severely  affected  with  iu-knee, 

as  shown  by  the  obhquity  of  the  articular  surfaces  .         .         46 

18.  View  of  out-knee  curvature  (genu- varum),  from  Mikulicz    .         50 

19.  ,,        the  normal  relation  of  femur  and  tibia    ...         50 

20.  ,,        considerable  in-knee  distortion  (genu-valgum)  .         50 

21.  ,,  the  bones  of  a  considerable  in-knee  when  placed  in 
their  normal  relation,  to  show  the  manner  in  which 
nature  then  fills  up  the  gap  before  alluded  to  .         .         .         51 

22.  Anatomical  representation  of  the  relation  of  the  thigh  and 

leg  during  over-fatigue  and  the  carrying  of  heavy  weights, 

for  which  we  are  indebted  to  Mr.  Alexander  Shaw  .         .         53 

23.  Contains  three  views  from  Mikulicz,  showing  the  progressive 

increase  of  the   diaphysial  portion  of  the  internal  and 
lower  part  of  the  femur,  and  slightly  of  the  epiphysis      .         55 

24.  Genu-valgoid  distortion  of  knee  disease         ....         62 

25.  Complete  ankylosis  of  knee  with  genu-valgoid  deformity     .         63 

26.  Genu-valgoid  distortion,  taken  from  the  living   strumous 

patient      ..........         63 

27.  Extreme    destruction  of  the   external   condyle,   &c.,  from 

chronic  rheumatism  •••....         64 

28.  Front  view  of  slight  atonic  in-knee       .....         71 

29.  In-knee  with  hyper-extension  on  one  side,  out-knee  of  the 

other,  from  Macewen        .......         74 

30.  Extreme  in-knee,  with  local  and  general  rachitis  .         .         81 


XVI  CONTENTS. 

Flli.  FAliK 

31.  Extreiue  rachitic  arrested  ilevelnpmrnt,  wilh  in-kuees  and 

curvatures,  from  Bouvier  ......  82 

3'2,  33.  Tyjncal  distortion  of  the  epiphysis  of  tibia  and  til)ula      .  84 

34.  Lt)rd()sis,  from  atonic  rehixation  ?  .....  85 

35.  Shght  paralytic  f<enii-valf(nm         ......  92 

36.  Severe  paralj'sis,  with  in-kuee       ......  93 

37.  Most  severe  paralysis,  with  in-knce  and  paralytic  talipes- 

varus         ..........         94 

38.  ISpasmodic  knock-knees,  combined  with  flexion  of  knees  and 

tahpes-cqninus           ........  95 

39.  Ordinary  leg  and  foot  curvatures  of  rickets  ....  102 

40.  llickety  out-knee  curvatures  (bow-legs)         ....  103 

41.  Accommodation    curves   in    lower   limbs    and    spine   from 

I)aral3-sis   .         .         .         .         .         .         .         .         .         .104 

42.  Ordinary'  rachitic  curve  in  shaft  of  long  bone         .         .         .       105 
43,44.  Manner  of  manipulating  in-knees   .....       115 

45.  Adjustable  splint  for  back  of  knee  .....       117 

46.  Side  splint  for  meelianical  treatment    .         .         .         .         .118 

47.  Shows  four  figures  of  in-knee  at  different  periods  of  treatment       124 

48.  Shows  the  thigh  and  leg  bones  of  a  genu-valgum  anatomical 

specimen,  from  Mikulicz  .......       137 

40.  The  same,  placed  by  us  in  a  nearly  natural  position  to 
indicate  by  dotted  lines  the  amount  of  new  bone  and 
cartilage  required  to  be  deposited  for  cure  by  mechanical 
means,  without  such  obliquity  of  articular  surfaces  as 
may  leave  a  liability  to  relapse.  Compare  with  fig.  17, 
p.  46,  from  Mayer     ........       137 

50.  Front  view  of  the  condylar  end  of  femur,  from  Macewen, 

before  supra-condylar  osteotomy  had  been  performed, 
but  which  we  represent  luith  the  inoper  degree  of 
inclination  common  to  tolerably  severe  in-knee.  Com- 
pare fig.  36,  p.  146,  Macewen,  '  On  Osteotomy,'  1880        .       155 

51.  Front  view  of  the  same  femur  after  the  osteotomy  had  been 

performed,  and  the  operator  had  with  gentle  force 
brought  tlie  ankle  and  foot  into  a  straight  line  with  the 
thigh.  Compare  this  with  fig.  38  of  Macewen  (op.  cit.), 
p.  147,  and  with  the  remarks,  p.  15(),  in  this  work  .         .       155 

52.  Diagrammatic  representation  of  a  curved  tibia    .         .         .       160 


LIST   OF   DIAGRAMS. 

A.  To  show  the  gap  between  the  external  condyle  and  tibia  in 

atonic  in-knee  when  the  prominence  of  the  internal  con- 
dyle is  temporarily  reinoved     ......         27 

B.  Schematic  arrangement  of  curved  limbs       ....       100 

C.  „  ,,  apparatus  for  in-knee  .         .       119 

D.  ,,  ,,  adjustable  side  splints         .         .       122 


CoiiUiGENJjUM. — On  page  20,  line  12  from  above,  /o/'  tig.  'A  read  lig.  4. 


"  PBINCIPIIS  obsta:' 

We  have  placed  at  the  head  of  our  remarks  an 
oft-quoted  maxim,  because  we  hope  we  shall  have 
convincingly  shown  in  the  succeeding  pages  'that  the 
distortion  of  Avhich  we  have  treated,  though  one  of 
the  most  serious,  when  looked  at  either  as  a  mere 
unsightly  deformity  or  as  an  affection  which,  in  its 
advanced  stage,  renders  the  act  of  independent  walk- 
ing impossible,  is  one  which  is  completely  preventible 
by  the  commonest  care  of  the  medical  man  and 
parent. 

The  occurrence  of  in-knee  and  out-knee  has  been 
long  known,  but  its  etiology,  pathology  and  morbid 
anatomy  had  not  been  described  until  the  publica- 
tion of  our  lectures  on  deformities  in  the  'Lancet,' 
in  1843-4. 

Nevertheless  the  records  of  general  hospitals  show 
that  during  the  last  few  years  many  hundreds  of  cases 
of  in-knee  had  attained  to  so  great  deformity  and  in- 
utility that  surgeons  have  thought  themselves  obliged 
to  have  recourse  to  violent  methods  of  cure,  or  to  a 
serious  "operation,"  for  its  relief,  although  others, 
as  well  as  ourselves,  had  never  met  with  a  case  that 
did  not  recover  by  the  help  of  instrumental  means 
alone.   We  dare  not  say  that  in  all  the  cases  in  which 


XVlll 


osteotomy  has  been  performed  the  operation  was  un- 
necessary. We  (\o,  however,  affirm  that,  from  the 
descriptions  of  many  cases  which  we  have  read,  the 
operation  was  in  a  large  number  of  cases  unneces- 
sary, and  that  in  all  the  distortion  should  have  been 
arrested  in  the  earlier  stage. 

We  have  therefore  considered  it  needful  in  the 
following  pages  to  sift  the  writings,  within  our  reach, 
of  subsequent  writers,  in  search  of  facts  illustrative 
of  the  symptoms,  pathology,  morbid  anatomy  and 
treatment  of  the  distortion,  with  which  we  have 
interwoven  our  experience  of  the  last  four  decades. 
From  these  sources  we  believe  that  the  result  of  our 
labours  will  shed  fresh  light  upon  the  knowledge  of 
the  distortion,  its  nature,  its  prevention,  and  remedy. 
The  work  has  been  a  labour  of  love,  for  it  has  sup- 
plied us  with  clearer  views  of  several  problems  in 
regard  to  this  and  other  deformities,  and  has  raised 
our  esteem  and  regard  for  several  of  those  whose 
names  we  have  quoted,  who  have  been  simultaneously 
working  in  the  same  direction.  Nor  have  we  spurned 
recourse  to  some  writers  of  the  last  century,  who  have 
treated  of  some  of  the  subjects  we  have  touched  upon, 
for  as  Huxley  says:* — "The  growth  of  Science  is 
now  so  prodigiously  rapid  that  those  who  are  actively 
engaged  in  keeping  up  with  the  present  have  much 
ado  to  find  time  to  look  at  the  past,  and  even  grow 
into  the  habit  of  neglecting  it.  But  natural  as  this 
result  may  be,  it  is  none  the  less  detrimental.     The 

=■=    Address    at   the   meeting    of    the   British   Association   for   the 
Advancement  of  Science  at  Belfast,  1874  :  '  Fortnightly  Review.' 


XIX 


intellect  loses,  for  there  is  assuredly  no  more  effectual 
method  of  clearing  up  one's  own  mind  on  any  subject 
than  by  talking  it  over,  so  to  speak,  with  men  of  real 
power  and  grasp,  who  have  considered  it  from  a 
totally  different  point  of  view." 

Many  surgeons  have  based  their  treatment  upon 
the  unfounded  belief  that  considerable  enlargement 
of  the  internal  condyle  existed ;  others,  that  curvature 
and  enlargement  of  the  internal  and  lower  part  of  the 
diaphysis  of  the  femur  is  the  most  marked  feature 
of  the  distortion.  The  following  pages  will,  we 
believe,  prove  that  deficiency  of  the  external  con- 
dylar parts  of  the  femur  and  of  the  opposite  articular 
surface  of  the  tibia  demand  the  most  consideration, 
whatever  be  the  method  of  treatment  employed. 

In  the  body  of  this  work,  writing  from  memory, 
we  have  stated  that,  when  first  writing  on  the  subject 
of  atonic  infantile  and  adolescent  in-knee,  we  had 
considered  it  to  arise  always  from  rickets.  We  find, 
however,  that  so  long  ago  as  in  our  lectures  in  the 
'Lancet,'  1843-4,  we  stated*  our  view  of  atonic  or 
idiopathic  in-knee  in  the  following  words  : — "  When 
in  children,  from  imperfect  nutrition  or  assimilation, 
the  muscular  and  ligamentous  tissues  are  weak,  and 
particularly  if  this  weakness  of  ligament  and  muscle 
be  associated  with  stoutness,  the  articulations  of  the 
lower  extremities,  especially,  become  deformed,  pro- 
ducing the  affections  known  by  the  names  genu- 
valgum  (in-knee)  and  talipes-valgus  spurius  (flat- 
foot),    which    an    appropriate    treatment    promptly 

*  Little  :  '  On  Deformities,'  p.  23. 


XX 


relieves."  We  have  shown  (p.  9)  that  Harrison, 
writing  in  1827,  recognised  the  influence  of  weak- 
ness of  the  fibrous  structures  in  the  production  of 
in-knee  and  spinal  curvature. 

Our  thanks  are  due  to  Mr.  T.  Sulman,  draughts- 
man and  artist,  for  the  accuracy  and  skill  which  he 
has  devoted  to  several  new  and  original  engravings 
which  illustrate  the  work. 

London,  May,  1882. 


IN-KNEE    DISTORTION. 


ON   IN-KNEE    OE   KNOCK-KNEE    (GENU-VALGUM), 
AND  ITS  VAEIETIES. 


Tpie  term  knock-knee  is  very  appropriate  in  the  plural 
number,  but  is  often  inapplicable  when  one  knee  only  is 
slightly  affected,  for  in  that  case  it  is  not  constant  that  the 
affected  knee  knocks  its  fellow.  The  term  in-knee  well 
expresses  the  nature  of  the  affection.  The  Germans  some- 
times call  it  the  X-knee,  from  the  crossing  of  the  limbs  in 
severe  cases,  but  this  designation  is  also  inappropriate 
when  a  single  knee  is  affected,  and  because  crossed-legs 
distortion  may  arise  independently  of  genu-valgum.* 

By  genu-valgum,  in-knee,  should  be  understood  a  dis- 
tortion of  the  knee  joint,  and  should  be  distinguished  from  a 


Fig.  1. 

*  See  annexed  figure  from  Little 
on  '  Deformities,'  1853,  p.  174,  fig.  74, 
showing  an  uncommon  form  of  crossed- 
legs  caused  by  long  forced  retention  of 
thighs  in  a  crossed  position  through 
sloughing  over  the  hips.  This  distor- 
tion has  been  popularly  called  "  scissor- 
legs." 


2  IN-KNEE    DISTORTION. 

deformity  similar  in  appearance,  which  mainly  depends  upon 
curvature  and  changes  in  form  of  the  femur  and  tibia. 

Man}'  writers  have  treated  of  the  distortion  under  two 
forms  :  (1)  the  statical,  in  which  the  influence  of  gravity 
has  been  paramount  in  its  production ;  and  (2)  the  rachitic, 
in  which  softening  of  bones  has  been  the  primary  disturbing 
cause.  It  is,  however,  obvious  that  when  rachitic  softening 
has  taken  place,  and  the  sufferer  endeavours  to  assume  the 
erect  posture  and  to  effect  locomotion  in  that  posture, 
statical  influence  will  come  into  operation  as  well  in  the 
rachitic  form  as  in  that  denominated  statical,  _/>«;•  excellence. 

It  is  desired  in  this  section  to  draw  fully  the  attention 
of  surgeons  to  the  fact  that  genu-valgum  is  an  alteration  in 
the  form  and  relation  of  parts  of  the  knee  joint  which  is  apt 
to  accompany  several,  indeed  the  majority,  of  disordered 
states  to  which  the  knee  joint  is  liable,  either  in  their  early 
or  in  their  later  stages. 

We  lay  it  down  as  an  axiom  that  in  any  disorder  or 
disease  of  the  knee  structures,  active  or  passive,  through 
which  either  the  relations  of  parts  or  the  equilibrating 
forces  are  disturbed,  the  condition  or  distortion  termed 
genu-valgum  to  a  greater  or  less  extent  will  arise  unless 
interfered  with  by  art. 

Hence  it  may  be  said  that  there  are  almost  as  many 
clinical  varieties  of  genu-valgum  as  there  are  knee  affections, 
and  further  that  the  distortion  may  arise  even  in  a  perfectly 
healthy  knee,  when  owing  to  disorder  in  one  limb  the  sound 
one  is  over-laden  and  over-worked. 

In-knee  may  exist  at  birth  ;  it  may  originate  in  the  one- 
year-old  fast-growing  infant  from  the  want  of  mother's 
milk,  from  improper  and  from  too  watery  a  diet,  without 
rachitis ;  it  may  depend  upon  unequivocal  rachitis,  upon 
infantile  paralysis  and  spasm.  It  arises  (without  rachitis) 
less  frequently  in  the  later  years  of  childhood,  when  the 
child  has  been  debilitated  by  measles,  hooping-cough,  or 


VARIETIES.  3 

scarlet  fever,  and  has  been  permitted  during  convalescence 
to  resort  too  soon  to  standing  or  prolonged  exertion.  On 
the  approach  of  puberty  in  both  sexes  during  another  fast- 
growing  period,  say  from  the  twelfth  to  the  sixteenth  year, 
or  later,  liability  to  the  distortion  again  sets  in.  At  any 
period  before  adult  age  the  occurrence  of  white  swelling 
(strumous  synovitis)  is  apt  to  present,  besides  contraction 
of  the  joint  in  the  flexed  position,  manifest  inward  inclina- 
tion of  the  knee  with  corresponding  eversion  of  the  leg 
(genu  contractum  et  valgoideum) .  With  advancing  years  the 
rheumatic  knee,  especially  in  subjects  who  were  regarded  as 
strumous  in  their  youth,  besides  becoming  contracted  in  the 
flexed  position,  is  apt  to  assume  a  distinctly  valgoid  direction, 
with  marked  pain  in  the  neighbourhood  of  the  internal  lateral 
ligament  and  internal  condyle,  especially  when  attempts  to 
use  the  limb  are  made,  and  the  tendency  to  distortion  is  not 
checked  by  art. 

The  author  has  seen  several  cases  of  considerable  genu- 
valgum  in  tall,  robust  adolescents,  and  adults  affected  with 
undue  stoutness  (polysarcia),  inordinate  height  and  weight 
having  apparently  contributed  to  the  distortion. 

This  frequent  liability  to  the  complaint  under  so  many 
conditions  does  not  spring,  as  often  asserted,  from  the 
natural  form  and  relation  of  the  component  parts  of  the 
limb,  and  especially  of  the  articulating  surfaces  of  the  knee 
joint,  for  in  the  normal  state,  a  well-knit  knee,  the  active 
and  passive  structures,  the  moving  and  resisting  powers, 
are  so  well  balanced  that  the  most  perfect  symmetry  and  a 
large  reserve  of  capability  for  use  beyond  the  average  use 
exists. 

It  can  no  more  be  admitted  of  genu-valgum  than  of 
congenital  club-foot,  as  has  been  stated  by  some  surgeons, 
that  every  child  born  into  the  world  has  a  certain  degree 
of,  or  a  certain  tendency  to,  both  those  affections.  All  that 
can  be  admitted  is  that  when  disorder  or  disease  of  the 


IN-KNEE    DISTORTION. 


knee  or  foot  takes  place  and  distortion  ensues,  the  form  of 
the  distortion  will  1)e  determined  in  a  certain  direction, 
rather  than  in  other  directions,  by  the  natural  anatomical 
relations  and  functions. 

In  the  causation  of  genu-valgum  the  natural  greater 
size  of  the  internal  condyle,  the  naturally  adducted  position 
of  the  femur  in  relation  to  the  trunk  and  to  the  tibia,  the 
asserted  naturally  less  developed  condition  of  the  external 
articular  suface  of  the  til)ia,  the  known  greater  physiological 
range  of  the  abduction  of  the  tibia  over  adduction  in  some 
positions  of  the  knee,  cannot  be  regarded  as  primary  causes. 

We  equally  deny  the  primary  influence  of  contraction 
of  any  muscle,  e.  g.  the  biceps  femoris,  in  producing  the 
distortion,  except  where  its  origin  has  been  spasm. 

The  annexed  woodcut  figures  of  tolerably  severe  adole- 

FiG.  2. 


Moderate  knock-kiiee,  non-rachitic. 


DEGBEES.  O 

scent  genu-valgum  will  convey  to  the  uninformed  reader 
a  better  idea  of  the  distortion  than  words.  It  consists  of 
undue  inversion  of  the  thighs  to  the  extent  that  the  knees 
may  touch  (fig.  2)  or  overlap  one  another  (fig.  3);   the 

Fig.  3. 


Severe  atonic  neglected  Jnwcli-'knee,  arrived  at  the  adolescent  stage. 

legs  are  more  or  less  widely  abducted  as  regards  the  thighs, 
and  consequently  are  separated.  In  extreme  cases  the 
particular  change  of  relation  of  the  thigh  and  legs  is  so 
considerable  that  the  limb  may  entirely  cross,  sometimes 
to  the  extent  that  the  right  foot  presents  where  the  left 
should  do,  and  rice  versa.  As  the  distortion  augments,  the 
individual  when  attempting  locomotion  sinks  from  the 
upright  posture,  so  that   considerable   bending   of  knees 


IN-KNEE    DISTORTION. 


becomes  apparent.  This  bending  of  the  knees  diminishes 
the  deformity.  The  disappearance  of  the  deformity  on  full 
bending  the  knee  is  a  characteristic  symptom  even  of  genu- 
valgum  in  the  severest  forms.  In  the  earUer  stages  excessive 
extension  of  the  knee  (hyper-extension  to  10  or  15  degrees) 
may  also  be  present. 

It  will  be  observed  further,   in  fig.  4,  that   not  only 
marked  abduction  of  the  legs  has  taken  place,  but  that  the 

Fig.  4. 


Efichitic  in-lniee  durinfl  childhood.    In  this  drawing  one  foot  inclines  to 
I'anis,  the  other  to  valr/us. 

tibias  are  rotated  outwards  on  their  perpendicular  axes. 
The  distortion,  consisting  of  knee  inversion,  leg  abduction, 
and  outward  rotation,  is  greater  in  the  left  than  in  the 
right  limb.  The  internal  condyles  may  be  felt  and  seen  to 
be  unduly  prominent ;  that  of  the  left  leg,  which  has  been 
passed  in  front  of  the  right,  is  strongly  marked  in  the 
drawing.  The  external  condyle  is  concealed  in  the  charac- 
teristic hollow  or  angle,  which  obtains  in  genu-valgum  on 


IN-    OB   OUT-ANKLE   CO-EXISTING.  7 

the  external  aspect  of  the  knee.  Observers  differ  as  to  the 
state  of  the  ankle  in  knock-knee,  some  stating  it  to  be 
affected  with  valgus,  others  that  it  has  a  tendency  to  varus. 
It  would  be  more  exact  to  say  that  sometimes  the  foot ' 
exhibits  more  or  less  valgoid  tendency,  at  other  times  a 
varoid  tendency.  As  a  rule,  in  young  children,  the  inner 
ankle  will  be  found  to  have  more  or  less  sunk,  and  the 
point  of  the  foot  to  be  proportionately  turned  out ;  in  older 
patients  the  foot,  owing  to  the  efforts  of  the  patient  to  ease 
the  ankle  when  walking,  may  assume  the  reverse  position. 
Even  young  children,  who  are  brought  for  consultation  by 
parents  because  "they  turn  their  toes  in,"  when  seated, 
are  found  on  examination  to  have  incipient  knock-knee  and 
flat-foot  (spurious  valgus).  The  gait  is  in  all  stages  unsteady 
and  unsightly;  in  advanced  cases  the  upright  attitude  is 
impossible,  and  walking  is  effected  with  bent  knees ;  some- 
times attempts  at  locomotion  are  quite  given  up.  The 
individual  is  then  obliged  to  confine  himself  to  sedentary 
pursuits ;  the  resulting  want  of  exercise  leaves  the  limbs 
to  the  further  disturbing  influence  of  the  unused  thigh 
muscles,  which  results  in  aggravation  of  the  original 
deformity.  In-knee  is  not  only  a  very  frequent  distortion, 
but,  as  already  stated,  one  which  is  induced  by  primary 
causes  of  very  dissimilar  characters. 

H.  Mayer,*  Volkmann,!  C.  Hueter,t  and  Mikulicz, § 
describe  two  forms  of  the  complaint :  that  from  softening 
of  bones — the  rachitic ;  and  that  which  arises  from  undue 

*  H.  Mayer :  '  Die  Osteotomie ;  lUustrii-te  Medicinisclie  Zeitung.' 
July,  1852. 

f  Yolkmann : '  Hanclbucli  tier  AUgemeineu  und  speciellen  Chinirgie,' 
von  Pitlia  und  Bilrotli,  Erlangen,  1872. 

I  C.  Hueter :  '  Klinik  der  Gelenkki-ankheiten  mit  Einscliluss  der 
Ortliopiidie,'  1876. 

§  Mikulicz  :  '  Arcliiv  fiir  Klinisclie  Clnrui'gie,'  von  Dr.  B.  von 
Langenbeck,  vol.  xxi.,  1879. 


8  IN-KNEE   DISTORTION. 

augmentation  of  the  work  which  the  knee  joint  has  to 
perform  when  bearing  the  weight  of  the  trunk,  and 
especially  when  carrying  heavy  loads — the  idiopathic,  or 
statical  form.  They  mostly  regard  the  rachitic  form  as 
originating  in  childhood,  and  the  statical  that  which 
originates  in  adolescence.  Volkmaun  coincides  with  our 
views,  that  idiopathic  or  statical  in-knee  occurs  in  infants 
beginning  to  walk;  and  in  adolescents,  Volkmann  says 
between  the  ages  of  two  and  four  years,  and  between 
fourteen  and  seventeen.  It  will  be  seen  further  on,  that 
we  have  frequently  met  with  the  idiopathic  or  atonic  form 
during  the  first  year  of  infant  life. 

Many  observers  have  described  congenital  knock-knee ; 
and  C.  Hueter,  oj;.  cit.,  p.  263,  refers  to  "  a  kind  of  traumatic 
form,"  caused  by  accidental  dislocation  of  the  epiphysis  of 
the  tibia  in  early  childhood. 

Our  experience  enables  us  to  affirm  with  confidence 
that  the  distortion  may  originate  under  several  other  very 
different  predisposing  conditions,  all  operating  to  add 
valgoid  knee,  though  not  an  equal  degree  of  it,  to  the  pre- 
existing or  co-existing  disorder  or  contraction. 

Congenital  genu-valgum  is  rare  and  slight  in  amount, 
and  is  commonly  rachitic ;  sometimes  it  is  due  to  the  same 
cause  which  produces  co-existent  congenital  varus,  viz., 
convulsive  muscular  contraction  (retraction  musculaire  of 
Guerin).  Gravity,  in  its  ordinary  sense,  cannot  affect  the 
foetus  in  the  same  manner  that  it  influences  the  fast-growing 
infant  trying  to  stand  and  walk.  The  rachitic  foetal  limbs, 
however,  if  not  modifiable  in  utero  by  gravity,  are  probably 
sometimes  susceptible  of  external  influences,  e.g.,  pressure 
through  the  uterine  walls  of  the  neighbouring  maternal 
organs,  and  the  action  of  their  own  muscles. 

The  following  is  the  arrangement  of  the  non-congenital 
clinical  varieties  of  genu-valgum  we  have  adopted  : — 

a.  Atonic,  idiopathic,  statical  or  uncomplicated  genu- 


ATONIC    IN-KNEE. 


valgum,  not  rachitic,  in  infants  hand-fed  upon  improper 
and  too  watery  diet  before  or  when  beginning  to  walk. 

h.  As  in  older,  strong-limbed  children  who  had  for  one 
or  more  years  walked  perfectly  well  until  they  became 
affected  with  general  debility  followed  by  genu-valgum,  as 
a  sequela  of  scarlet,  gastric,  and  other  fevers ;  too  early 
return  to  the  use  of  the  limbs  in  such  persons  having 
engendered  weak  or  in-knees,  sometimes  accompanied  with 
other  distortions  caused  by  premature  use  of  trunk  and 
limbs,  such  as  scoliosis  and  flat-foot.     See  fig.  5. 

Fig.  5. 


Atonic  or  idiopathic  in-knee,from  debility  on  resuming  exercise  too  soon  after  acute 
illness,  not  racldtic.   From  Harrison,  on  '  Sinnal  Diseases,'  London,  1827. 

c.  As  in  adolescents,  not  rachitic,  suffering  from  general 
debility  caused  by  too  rapid  growth,  late  hours,  too  much 


10  IN-KNEE    DISTORTION. 

standing,  and  too  much  carrying  of  heavy  weights,  as  in 
pursuing  particular  mechanical  occupations,  often  aggra- 
vated amongst  the  very  poor  by  insufficient  feeding. 

d.  As  in  children  congenitally  weak,  with  congenital 
heart,  vascular  and  capillary  disease  (cyanosis),  or  lung 
disease  (atalectasis)  ;  rarely  from  non-congenital  heart 
disease. 

e.  From  over-use  of  a  sound  knee,  or  from  a  previously 
sound  knee  having  accommodated  itself  to  a  short  opposite, 
or  to  a  weak,  wasted  neighbour. 

/.  As  in  over-fed,  over- stout,  fat,  heavy  infants ;  over- 
stout  and  over-tall  adolescents. 

In  addition  to  these  varieties  of  genu-valgum,  as 
deduced  from  difference  of  origin,  all,  however,  being  alike 
in  the  circumstance  that  the  genu-valgum — the  morbid 
inward  inclination  of  the  knee — is  the  only  knee  joint 
affection,  there  is  a  series  of  knee  distortions  in  which 
inward  inclination — a  genu-valgoid  direction — of  the  joint 
is  an  important  and  striking  element,  though  not  the  more 
important  part  of  the  disorder.  They  might  be  termed 
sub-forms  of  genu-valgum,  and  those  forms  a  to  /,  already 
defined,  in  which  the  inward  inclination  of  the  knee  con- 
stitutes the  whole  of  the  deformity,  might  be  termed  true 
or  genuine  in-knee  ;  and  those  in  which  the  genu-valgum 
is  the  minor  part  of  the  affection  might  be  termed  false  or 
si)urious  in-knee.  This  denomination  of  cases  would  cor- 
respond Avith  the  manner  in  which  we  speak  of  true  or 
complete  (meaning  bony)  ankylosis,  and  false  or  spurious 
(meaning  fibrous)  ankylosis ;  or  as  we  speak  of  true  talipes 
valgus  (meaning  congenital  or  complete)  and  spurious  talipes 
valgus  (meaning  rachitic  talipes  valgus,  or  flat-foot). 

g.  For  convenience  sake  here  we  will  drop  the  expression 
sub-form,  and  speak  of  the  next  variety  as  the  paralytic  or 
spastic  one,  arising  from  partial  paralysis  or  spasm  of  the 
muscles  moving  the  knee  joint.     These  cases,  except  as  to 


VARIETIES.  11 

the  disordered  innervation,  are  closely  allied  to  the  former 
varieties  a  to/. 

h.  From  rachitis.  It  will  be  hereafter  shown  that  in 
this  form  cm^vature  of  the  thigh  and  leg  bones  plays  as 
important  a  part  in  the  deformity  as  the  articular  knee 
structures,  if  not  a  more  important  part. 

i.  From  rheumatic,  strumous  and  traumatic  knee 
affections.  In  synovitis,  whether  rheumatic,  strumous,  or 
the  effect  of  accident,  the  often  long-continued  distention  of 
the  joint  and  the  impairment  of  joint  structures  immediately 
due  to  the  congestion  or  inflammation,  are  the  causes  of 
weakness,  and  relaxation  of  the  connection  of  the  bones 
with  each  other,  upon  which  is  apt  to  follow  contraction  in 
the  bent  position,  sub-luxation,*  and  a  genu-valgoid  form  of 
the  joint  with  abduction  of  the  tibia. 

It  will  now  be  seen  that  each  of  these  primary  causes  of 
in-knee,  except  e,  which  results  from  "accommodation," 
which  is  an  example  of  the  complaint  having  been  produced 
by  a  cause  acting  outside  of  the  affected  limb,  operate  by 
lessening  the  tone  or  strength  of  some  or  all  of  the  active 
and  passive  structures  of  the  joint  itself, — the  muscles, 
the  ligaments,  and  the  bones.  The  secondary  or  determining 
causes  are,  as  will  be  seen,  the  form  and  bearing  of  the 
articular  surfaces  of  the  femur  and  tibia  upon  each  other, 
and  the  action  of  gravity,  &c.,  of  the  weight  of  the  head, 
upper  extremities  and  trunk  upon  the  enfeebled  and 
loosened  joint,  modified  in  the  case  of  rickets  by  the 
peculiar  form  acquired  by  the  thigh  and  leg  bones  in 
severe  rachitic  instances  of  this  deformity. 

From  this  enumeration  of  the  clinical  and  pathological 
varieties  of  in-knee  it  will  be  understood  why  neither  con- 

■•'  The  important  and  miscliievous  part  performed  bj'^  sub-luxation 
of  the  tibia  in  knee  joint  diseases  was,  it  is  beheved,  first  pointed  out 
by  the  author.  See  lectures  on  "  Contractions  and  Deformities  "  in  the 
'  Lancet,'  1842 — 3 ;  and  also  in  '  Treatise  on  Ankylosis,'  London,  1843. 


12  IN- KNEE    DISTORTION. 

currence  with  the  views  of  those  recent  authors  who  divide 
the  cases  into  two  forms  (the  rachitic  and  statical),  or  with 
C.  Hueter,  who  adds  a  third  form  (the  traumatic),  nor  still 
less  with  those  who  see  in  the  distortion  of  in-knee  a 
single  form  (that  of  rachitic  origin),  can  be  arrived  at. 
When  in-knee  is  looked  at  from  an  etiological  and  con- 
stitutional point  of  view,  it  will  be  evident  that  all  cases, 
including  the  rachitic  ones,  might  equally  be  called  statical ; 
that  in  all,  the  weight  of  the  body  being  attempted  to  be 
inefficiently  borne  by  the  limb  causes  the  passive  structures 
to  yield  beneath  its  influence. 

The  principal  conclusions  at  which  we  have  arrived  in 
this  section  are  that  there  are  several  clinically  and  patho- 
logically well-marked  varieties  of  in-knee,  and  that  of  these 
varieties  the  rachitic  is  not  the  most  frequent. 


OUTWARD   CURVATUEE   OF   KNEE. 

Cases  of  an  opposite  form  of  distortion  of  the  knee,  see 
fig.  6,  termed  outward  yielding  or  curvature  of  it  (genu- 
extrorsum*),  are  occasionally  met  with,  mainly  in  rachitic 
subjects.  It  is  much  less  frequent  than  genu-valgum,  or 
inward  inclination.  The  greater  frequency  of  the  latter  is 
apparently  due  to  the  natural  inward  direction  of  the  shaft 
of  the  femur  and  condyles. 

The  immediate  or  mechanical  cause  of  outward  knee 
inclination  has  not  been  satisfactorily  explained.  It  is  com- 
monly of  rickety  origin,  and  is  combined  with  curvature  of 
the  femur  and  tibia.  When  one  knee  is  inclined  inwards 
and  the  other  outwards,  the  latter  appears  as  if  it  were  the 
result  of  accommodation.  It  may  also  occur  independently 
of  rickets,  as  when  one  limb  is  shortened  from  paralysis, 

=^  We  were  the  first  to  name  and  describe  geuu-extrorsum  curvatum 
at  the  Royal  Ortboptedic  Hospital  in  1839. 


OUTWAED    KNEE    DISTOETION. 


13 


knee  disease,  or  accident,  the  other  limb  yielding  outwards 
for  accommodation  purposes. 


The  annexed  figure  exhibits  a  case 


Fig.  6. 


of  considerable  outward  curvature  of 
doubtful  origin.  There  exists  obvious 
curvature  of  all  the  long  bones  of  both 
lower  extremities,  but  they  are  dispro- 
portionately long,  the  reverse  of  the 
shortened  limbs  of  a  rickety  subject.  The 
individual  had  not  the  head  and  face  of 
rachitis,  nor  were  other  signs  of  former 
rickets  present.  He  had  a  puny  chest 
and  lanky  legs,  common  to  the  ill-fed 
fast-growing  atonic  cases  of  distortion 
(such  as  genu- valgum  atonicum),  and 
may  have  followed  an  avocation  which 
had  predisposed  to  distortion.  It  is  well 
known,  for  example,  that  jockeys  are  apt 
to  become  bow-legged.  As  the  lower 
extremities  are  comparatively  long  com- 
pared with  the  trunk,  it  is  probable  that 
the  over-growth  and  the  curvature  took 
place  during  the  most  active  period  of  growth,  from  about 
the  age  of  twelve  or  thirteen  to  sixteen  or  seventeen. 

The  disproportion  is  so  unusually  great  as  to  suggest 
the  idea  that  it  was  due  to  excess  in  growth  (deformity 
from  excess),  with  proportionate  weakness  and  liability  to 
yield  to  gravity,  and  to  any  undue  retention  of  the  limbs  in 
a  particular  position. 


Double  outward  curva- 
ture of  loicer  extre- 
mities. 


PATHOLOGY  AND  MOEBID  ANATOMY  OF  IN- 
KNEE,  AND  ITS  VAEIETIES. 


We  have  already  stated  (pp.  2, 11)  that  every  disordered 
condition  of  the  structures  composing  and  surrounding  the 
knee  joint,  the  integrity  of  which  is  necessary  for  the  due 
performance  of  its  functions,  may  give  rise  more  or  less 
completely  to  knock-knee. 

The  essential  first  evil  consequence  of  disordered  action 
is  a  weakening  of  the  naturally  strong  connection  which 
exists  between  the  femur  and  tibia.  If  the  weakening  affect 
the  ligaments  the  joint  is  at  the  mercy  of  the  muscles,  the 
stronger  ones  asserting  their  supremacy ;  and  if  the  indi- 
vidual is  able  to  attempt  to  stand  or  walk  the  influence  of 
gravity  becomes  irresistible,  the  joint  yields  to  it,  constituting 
displacement  or  distortion.  If  the  primary  evil  be  in  the 
muscles  it  will  consist  of  either  augmented  power  (spasm) 
or  diminished  power  (paralysis),  or  a  modification  of  that 
less  considered  and  less  completely  defined  property  known 
as  tone. 

We  have  shown  that  from  disordered,  or  probably  rather 
from  insufficient  nutrition  of  tissues,  both  ligaments  and 
muscles  suffer  from  diminished  tone  and  strength,  and  that 
genu -valgum  arises  more  often  from  loss  of  tone  than  from 
any  other  single  cause.  Nevertheless  pathologists,  when 
treating  of  this  distortion  and  of  distortions  in  general,  ex- 
cept as  regards  scoliosis,  miscalled  lateral  curvature,  have 
seldom  taken  atony  of  fibrous  and  muscular  structures  into 
account.     The  popular  term  weakness  has  taken  its  place. 


RELATION    TO    OTHER   DISEASES.  15 

Atonic  genu-valgum  is  related  to  several  other  disorders 
in  which  weakness  of  fibrous  structure  (including  muscular 
weakness,  short  of  paralysis)  exists,  e.g.,  prolapsus  ani, 
prolapsus  uteri,  ectropium  senile,  hernia,  fiat-foot,  &c. 
Those  complaints  which  depend  upon  muscular  weakness 
(atony)  have  more  attracted  the  notice  of  pathologists  than 
those  in  which  weakness  of  ligaments  plays  the  more  im- 
portant part.*  This  oversight  as  to  the  important  part 
played  by  atony  of  fibrous  structures  and  muscles  is  partly 
due  to  the  positive  material  tendency  of  pathology  during 
the  last  four  or  five  decades.  That  which  is  apt  to  be  reco- 
vered from  does  not  afi"ord  material  for  the  scalpel  or  micro- 
scope (without  resort  to  the  emporte-inece,  a  proceeding  little 
to  be  commended  and  rarely  employed).  We  do  not  despair 
that,  attention  being  drawn  to  the  subject  of  atony  of  fibrous 
and  muscular  structures,  more  will  hereafter  be  known  re- 
specting its  essential  nature. 

Gravity  usually  tells  unfavourably  against  atonic  struc- 
tures; consequently  in  the  case  of  atonic  distortions  the 
ankle  joint  suffers  most  from  this  cause  (flat-foot),  next  the 
knee  (genu-valgum),  next  the  hip  (certain  waddling  gait,! 
when  not  caused  by  rickety  change  in  the  neck  of  femur), 
lastly,  the  spinal  column  (scoliosis). 

As  an  instance  of  imperfect  gait  from  want  of  tone  of 
parts,  we  may  cite  the  hobbledehoy  movement  of  a  fast- 
growing  adolescent  boy,  one  who  has  "outgrown  his 
strength,"  the  power  of  co-ordinating  his  muscles  (apart 
from  a  possible  touch  of  chorea)  has  been  outdone  by  the 
over-rapid  elongation  of  the  bones  of  the  lower  extremities 
proper  to  this  period  of  life.  We  have  occasionally  been 
consulted  as  to  adolescent  girls  in  whom,  as  in  the  above 
class  of  boys,  we  could  discover  no  distinct  disease,  yet  the 

*  Consult  Louis  F.  Stromeyer :  Platt-fuss  '  Beitrage  zur  Operativen 
Orthopaedik,'  Hanover,  1838.  Ernst  Stromeyer :  '  Ueber  Atonie 
fibroser  Gewebe,'  Wurzburg,  1840. 


16 


IN-KNEB    DISTORTION. 


gait  was  extremelywanting  in  steadiness  and  firmness,  some- 
times amounting  in  the  minds  of  the  attendants  to  lame- 
ness of  hip.  It  is  a  question  in  some  such  cases  of  want  of 
tone  in  the  hgaments  and  muscles  attached  to  the  rapidly 
enlarging  pelvis,  analogous  to  the  hobbledehoy  gait  caused  by 
rapid  elongation  of  the  bones  of  the  boy's  lower  extremities. 
We  have  elsewhere  stated  that  we  have  known  even  a  girl 
grow  six  inches  in  a  year,  just  before  pubert3^  The  case 
was  one  of  incipient  scoliosis.  We  had  periodically  measured 
her  during  the  year,  as  an  aid  in  determining  the  pro- 
bability of  cure. 

Hitherto  it  has  not  been  sufficiently  noted  that  there  are 
two  periods  in  the  age  of  man  at  which  growth  is  extra- 
ordinarily rapid.  The  first  period  is  from  birth  until  the 
age  of  nine  months ;  the  second  period  is  at  the  approach 
of,  or  during,  puberty  or  adolescence,  say  from  the  tenth  or 
twelfth  to  the  fourteenth  or  sixteenth  year,  more  or  less. 

We  are  indebted  to  Burdach  *  and  Schwartz  for  precise 
details  on  this  interesting  head.  Schwartz  watched  a  child 
which  grew  in  the 


First  week 

H 

in. 

,,     month 

2 

3  lines.! 

Second    ,, 

1 

1  line. 

Third      „ 

0 

7  lines. 

Fourth    „ 

0 

11     „ 

Fifth       „ 

0 

6     „ 

Sixth       „ 

0 

7     „ 

Seventh  ,, 

1 

Eighth  and  n 

mth  month 

H 

■■'  Carl  F.  Burdacli :  1880,  '  Die  Physiologie  als  Erfaliruugswissen- 
schaft,'  3  Band,  p.  236. 

•j-  We  were  led  to  enquire  into  this  subject  through  having  repeat- 
edly observed  how  very  often  in  the  treatment  of  congenital  varus  in 
infants  during  "the  month"  it  became  necessary  to  exchange  the 
splints  used  for  longer  ones. 


GBOWTH   DURING    INFANCY   AND    ADOLESCENCE. 


17 


. 

3  in. 

. 

2  „ 

. 

2  „ 

. 

2  „ 

. 

1  „ 

. 

1  „ 

If  in 

the  first  seven 

22  inches,  it  will  in- 

so  that  its  length  increased  in   nine  months  about  one- 
third,  say  8^  German  inches.* 

The  average  rate  of  growth  in  the  infant  is  estimated  to 
be  6  to  8  German  inches  during  the  first  nine  months,  or 
from  18  or  20  inches  to  24  or  26  inches.  Burdach  says  that 
growth  is  during  the 

Second  year 

Third 

Fourth 

Fifth 

Sixth 

Seventh 
at  which  period  there  is  often  a  stop, 
years  the  length  has  increased  20  or 
crease  in  the  second  seven  years  only  10  or  12  inches,  and 
attains  in  the  male  5|-  feet.  The  weight  which  at  seven 
years  is  37  lbs.  German,  increases  at  the  age  of  fourteen 
22  or  25  lbs. 

Adolescence  extends  from  puberty  to  completion  of 
growth,  i.e.,  until  sixteenth  to  twenty-third  year  in  the  male,; 
and  fourteenth  to  twentieth  in  the  female.  Growth  at  the 
beginning  of  this  period  proceeds  rapidly,  and,  especially  ini 
cases  where  it  had  not  greatly  advanced,  makes  a  fresh  start. 
During  adolescence  the  growth  is  from  10  to  12  inches.  W^ 
believe  that  in  the  male  growth  may  not  stop  until  the  age 
of  twenty-five.  It  is  known  that  ossification  is  not  com- 
pleted before  thirty.  It  was  stated  at  the  meeting,  in  1881, 
of  the  British  Association  for  the  Advancement  of  Science, 
that  growth  continues  until  the  age  of  forty ;  probably  in 
width  only. 

These  two  periods  of  most  rapid  growth  are,  we  venture 
to  say,  predetermined  physiologically :  the  first  to  hasten 


*  n  .    ,       128 

*  German  inch  =  vtt? 

loo 
1-098  English. 


•9519  EngUsh.     German  pound 


56 
51 


18  IN-KNEE    DISTORTION. 

the  infant's  fitness  for  independent  locomotion  and  self-help 
to  food,  when  the  mother's  poAver  of  lactation  may  in  the 
normal  com'se  he  expected  to  cease,  and  the  infant's  ahso- 
lutc  dependence  on  the  mother  for  hoth  locomotion  and  food 
shall  terminate  ;  the  second  period  is,  we  consider,  allied  to 
sexual  development,  and  the  [ipparent  necessity  of  then  more 
rapidly  completing  the  frame  of  the  individual  of  either  sex 
to  fit  it  for  propagation  of  the  race,  for  a  life  of  lahour,  and 
its  defence  against  dangers. 

Volkmann  (oj).  cit.)  applies  the  term  idiopathic  to  denote 
what  we  have  termed  the  atonic  form  of  genu-valgum,  and 
remarks  that  it  occurs  almost  without  exception  only  be- 
tween the  second  and  fourth  and  between  the  fourteenth 
and  seventeenth  years.  He  appears  to  attribute  it  to  abso- 
lute overloading,  whilst  we  attribute  it  in  infancy  and  early 
childhood,  as  a  rule,  to  relative  overloading  of  the  joint 
which  is  relaxed  from  atonic  causes.  In  adolescents  it  is 
probable  that  the  carrying  of  heavy  weights,  fatigue,  and 
long  hours  of  work,  have  the  principal  share  in  its  pro- 
duction, favoured  in  fast-growing  lads  by  insufficient  diet, 
and  consequent  weakness  of  tissue.  Volkmann  is  the  only 
observer  who,  besides  ourselves,  as  far  as  we  have  ascer- 
tained, recognises  the  fact  of  atonic  genu-valgum  taking 
place  mainly  at  two  epochs  of  life.  We  have  never  seen  a 
rachitic  in-knee  produced  after  the  age  of  five  years.  Pre- 
vious observers  and  statistical*  enumerators  speak  of  cases 
of  rickets  originating  during  adolescence,  and  even  adult 
age.  They  have  often,  doubtless,  included  under  the  head 
of  rickets,  as  originating  during  adolescence,  cases  which 
had  commenced  in  early  childhood,  and  cases  of  the  simjAe 
loeak  in-knee  of  early  infancy  and  adolescence,  all  of  which 
are  liable  to  become  aggravated  through  statical  influences 
during  rapid  growth.     Simple  in-knee  without  unequivocal 

■■'  See  the  "Discussion  ou  Eickets"  at  the  Pathological  Societj', 
December,  1880,  in  the  medical  journals  of  the  period. 


INFLUENCE    OF    GROWTH.  19 

signs  of  rickets  may  originate  at  any  period  between  birth 
and  the  completion  of  growth,  but  occm-s  by  far  the  most 
frequently  in  early  infancy  and  during  the  progress  of 
puberty  and  adolescence,  corresponding,  in  fact,  with  the 
two  rapid  periods  of  growth  to  which  we  have  alluded. 

Simple  or  weak  in-knee  occurs  independently  of  the  pre- 
sence of  signs  of  rickets.  Eickety  in-knee  is  accompanied 
with  constitutional  and  local  signs  of  rickets  elsewhere ; 
rachitic  bone  curvatures,  for  example,  rickety  teeth,  rickety 
face  and  skull,  restricted  growth.    (See  rickety  in-knee.) 

Simple  in-knee  from  weakness  attacks  tall  children,  and 
does  not  lead  to  shortening  of  their  stature.  Rickety  genu-! 
valgum  is  met  with  only  in  individuals  stunted  from  rickets, 
i.  e.,  shortened  more  or  less  according  to  the  intensity  of 
that  disease.* 

As  regards  the  proximate  causes  of  genu-valgum  and 
their  anatomical  results,  the  opinions  which  have  had  more 
or  less  temporary  currency  during  the  last  forty  years  may 
be  summarised  by  saying  that  some  observers,  through  not 
having  taken  a  comprehensive  view  of  knock-knee,  or  from 
not  having  had  sufficient  opportunities  of  studying  the  dis- 
tortion in  all  its  forms  and  stages,  have  singled  out  one  fact, 
often  not  a  constant  one,  in  the  history  of  the  complaint,  to 
which  alone  they  have  attributed  its  origin.  Thus  one  writer 
has  attributed  it  to  elongation  of  the  internal  lateral  liga- 
ment of  the  knee  joint ;  another  to  shortening  of  the  external 
lateral  ligament ;  another  to  contraction  of  the  outer  ham- 
string, muscle  and  tendon  ("retraction  musculaire"), — a 
great  number  of  writers  have  put  down  enlargement  of  the 
internal  condyle  of  the  femur  as  the  immediate  cause. 
Gradually  deficiency  of  the  external  condyle  has  obtained  a 
share  of  the  etiologist's  attention.  Finally,  it  is  acknow- 
ledged that  when  the  distortion  has  long  existed,  deficiency 

*  See  also  paper  by  the  author  in  tlie  '  Transactions  of  tlie  Inter- 
national Medical  Congress,'  London,  1881. 


20 


IN-KNEE    DISTORTION. 


of  the  external  condj^le  and.  enlargement  of  the  internal 
condyle  co-exist.  In  our  opinion  these  several  conditions 
grow  up  jxiri  j^assu,  or  successively,  and  appear  as  factors 
of  the  deformity.  The  time  has  arrived  when  it  may  be  said 
that  the  majority  of  the  above  conditions  are  but  conse- 
quences of  a  common  cause, — a  weakening  of  the  j&brous 
structures  and  bones  affecting  the  knee  joint,  which  becomes 
statically  disturbed  by  gravity,  by  passive  muscular  action, 
and  may  even  be  influenced  by  the  will  of  the  patient  in  his 
efforts  to  eflect  locomotion  in  the  least  uneasy  manner  when 
the  distortion  has  reached  the  highest  stage  ;  and  through 
inability  of  the  patient  to  take  any  exercise  the  members 
may  become  surrendered  to  the  passive  adaptive  shortening 
of  muscles,  and  get  more  or  less  rigidly  fixed  in  the  deformed 
state. 

One  of  our  ablest  surgeons,  author  of  a  '  Monograph  on 
Genu- valgum,'  Macewen,  attributes  it  exclusively  to  rickets, 
and  in  particular  to  curvature  of  the 
lower  end  of  the  femur  and  hyper- 
trophy of  the  internal  condyle  and 
adjacent  part  of  the  shaft.  It  may 
here  be  remarked  that  curvature  of 
the  tibia  is  sometimes  a  more  promi- 
nent fact  in  rickety  genu-valgum  (see 
fig.  7)  than  femoral  curvature,  or 
inward  inclination  of  the  knee  joint 
itself. 

We   refer   knock-knee    in    all   its 
forms  primarily  to  relative  or  abso- 
lute weakness  and  relaxation  of  the 
structures  composing  and  surround- 
ing the  knee  joint,  the  ordinary  state 
of    perpendicularity   of    the   whole    limb   being   disturbed 
through  the  weight   of  the  head,  upper  extremities   and 
trunk  being  too  great  to  be  properly  borne  by  the  enfeebled 


Fig.  7. 


Racliitic  (lemi-vahjuiit  and 
curvature  confined  to  one 
le<i,  from  flayer. 


PATHOLOGICAL    CHANGES.  21 

and  strained  knee  structures.  It  follows  that  the  resulting 
distortion  of  the  articular  surfaces  in  genu-valgum,  whether 
preceded  by  the  weakness  of  over-growth,  by  rickets,  by 
paralysis,  or  by  articular  disease,  should  present  more  or 
less  similar  mechanical  altered  relations  in  all  cases. 

The  minute  pathological  conditions,  when  fully  known, 
will  probably  be  found  to  differ  as  much  as  the  constitutional 
conditions  of  the  system  at  large  differ  in  the  several 
causatory  disorders  above  named.  C.  Hueter  and  Mikulicz 
have  ably  demonstrated  the  minute  changes  of  the  articular 
ends  of  the  bones,  as  shown  by  microscopical  examination 
in  genu-valgum  caused  by  the  action  of  rachitis.  We  are 
at  present  ignorant  of  the  minute  changes  in  the  bones  and 
fibrous  structures  of  children  fed  on  too  watery  a  diet,  and 
in  paralysis  and  other  causes  of  the  distortion. 

In  confirmation  of  this  view,  that  however  different  may 
have  been  the  primary  constitutional  condition,  and  what- 
ever the  secondary  or  determining  causes,  either  in  infancy 
or  adolescence,  such  as  over-much  standing  or  walking  in 
the  former,  or  the  pursuit  of  particular  occupations  neces- 
sitating much  standing  and  carrying  heavy  weights  in  the 
latter,  the  mechanical  conditions  are  the  same,  we  may 
quote  C.  Hueter's  {op.  cit.,  p.  263)  emphatic  assertion.  We 
premise  that  Hueter  appears  only  to  have  met  with  three 
forms  of  genu-valgum :  the  rachitic,  beginning  in  young 
children ;  the  statical,  as  he  erroneously  says,  arising  only  in 
growing  youths  without  obvious  rickets  ;  and  the  traumatic. 
He  says  :  "  When  I  reflect  upon  the  number  of  cases  of  both 
kinds  which  I  have  watched,  I  believe  them  to  be  essentially 
different,  not,  it  is  true,  in  relation  to  their  clinical  symp- 
toms and  pathologico-anatomical  results, — for  these  are  in 
both  forms  identical, — as  they  are  also  in  their  chronolo- 
gical, etiological,  and  therapeutical  relations."  We  consider 
Hueter  to  be  quite  mistaken  in  attributing  identical  clinical 
symptoms  and  anatomico-pathological  results  to  rachitic 


22  IN-KNEE    DISTORTION. 

in-knee  which  begins  in  childhood,  and  the  statical  which  he 
believes  originates  onl}'  in  adolescence.  Pathologically,  as 
well  as  clinically,  rachitic  genu- valgum  is  in  the  early  stages 
distinguishable  from  all  other  forms  by  its  being  complicated 
with  curvatures  of  the  shafts  of  the  thigh  and  leg  bones,  as 
well  as  by  rachitic  affection  of  other  parts.  See  further  on 
as  to  co-existence  of  two  forms  of  disease. 

In  studying  the  subject  of  the  influence  which  the  natural 
form  and  relations  of  parts  concerned  in  the  knee  joint  may 
exercise  upon  the  production  of  genu-valgum,  it  becomes 
necessary  to  review  some  of  the  opinions  of  surgeons  upon 
it.  This  is  especially  needed,  as  many  believe  that  the  dis- 
tortion is  due  to  the  naturally  greater  length  of  the  internal 
condyle.  Some,  speaking  of  the  normal  femur,  have  attri- 
buted too  great  an  excess  to  the  normal  internal  condyle. 
Holden,*  for  example,  attributes  to  the  internal  condyle 
an  excess  of  half  an  inch.  When  handling  the  bone,  or 
suspending  it,  it  may  be  looked  at  in  an  unnatural  position. 
Naturally,  the  femur  is  attached  to  the  trunk  in  such 
manner  that  its  lower  portion  inclines  towards  the  median 
line  of  the  body  sufficiently  to  bring  the  two  condyles  on 
nearly  the  same  plane,  so  as  to  correspond  with  the  two 
usually  nearly  level  articular  surfaces  of  the  tibia.  This 
fact  disposes  of  the  notion  that  the  internal  condyle,  being 
naturally  half  an  inch  longer  than  the  external  one,  acts  as 
a  direct  cause  of  genu-valgum. 

In  the  annexed  fig.  8  are  represented  two  femurs,  taken 
at  random  from  amongst  others.  The  first  {a)  is  a  well- 
formed  bone  of  a  tall,  probably  slender  individual,  in  which 
the  length  and  breadth  of  the  internal  condyle  are,  accord- 
ing to  the  norm,  greater  than  of  the  external  condyle.  When 
placed  as  nearly  upright  as  possible  against  a  wall  it  is  seen 
that  the  prominence  in  a  of  the  internal  condyle  below  is 
very  small,  and  is  only  sufficient  to  occasion  the  slight 
*  Holcleu  :  '  Humau  Osteology.' 


LENGTH    OF    INTERNAL    CONDYLE. 


23 


natural  obliquity  or  adduction  of  the  shaft.    The  other  bone 
(h)  is  shorter,  heavier,  possibly  from  rachitis,  more  bulky  in 


Fig.  8. 


Fig.  9. 


Fig.  8.~ -Front  viexo  of  hvo  femora:  (a)  norvml  hone;  (b)  believed  to  be 
taken  from  a  rickety  subject.  They  were  jihotographed,  the  loicer  ends  resting 
on  a  horizontal  table,  and  the  upper  ends  resting  against  an  upright  xoall. 

Fig.  9. — Copy  of  photograph  of  the  front  vieiv  of  the  same  two  femurs  :  (rf) 
has  the  longer  internal  condyle,  but  on  contrasting  (b)  and  (d)  it  will  be  observed 
that  the  placing  three  bronze  pennies  beneath  the  external  condyle  suffices  to 
produce  in  this  plwtograph  the  same  inward  inclination  of  the  shaft  of  the 
thigh  as  (a)  and  (c)  exhibit. 

all  respects,  except  as  to  length ;  all  the  processes  and  the 
caput  much  more  pronounced,  and  the  neck  more  hori- 
zontal ;  probably  the  bone  of  a  stouter  individual,  and  one 
accustomed  to  carry  heavy  burdens.  This  second  femur, 
when  similarly  placed  resting  upon  the  table  and  against 
the  wall,  as  nearly  upright  as  possible,  exhibits  a  greater 
obliquity  or  adducted  position  of  the  shaft.  At  d  (fig.  9)  it 
is  seen  that  three  penny  bronze  pieces  (=  0*18  inch,  or 


24 


IN-KNEE    DISTORTION. 


4*57  millimetres),  placed  beneath  the  external  condyle,  are 
all  that  is  required  to  give  this  second  bone  the  appearance 
of  possessing  the  smaller  degree  of  obliquity  or  adduction  of 
the  shaft,  as  in  the  neighbouring  bone  (c).  We  next  direct 
attention  to  e  and/  (fig.  10),  which  represent  the  back  view 

Fig,  10. 


Copy  of  photographic  hack  views  of  the  tihice  (/)  and  (c),  corresponding  to  the 
above  femurs  :  (e)  the  bach  view  of  tibia,  which  corresponds  to  the  femur  [b]  and 
(d) ;  (/)  is  the  back  view  of  the  tibia,  corresponding  to  the  femur  («)  and  (c). 

of  the  two  tibiae  corresponding  to  these  femora,  and  note 
that  the  femur  b  and  d  (in  figs.  8  and  9),  which  has  the 
longer  condyle,  has  the  deeper  articular  cavity  for  its  re- 
ception, as  seen  at  (*),  compared  with  the  articular  cavity 
at  (+).  Assuming  that  these  femurs  represent  comparatively 
small  development  of  internal  condyle,  we  consider  that 
they  show  that  the  relative  normal  superiority  in  length  of 
the  internal  condyle  has  been  much  exaggerated. 

In  like  manner  it  may  be  inferred  that  the  abnormal 
enlargement  of  the  internal  condyle  of  the  femur  in  genu- 


ATONIC    IN-KNEB. 


25 


Fig.  11. 


valgum  has  been  unintentionally  exaggerated  from  observers 
having  in  their  estimate  compared  it  to  the  external  condyle, 
the  development  of  which  has  been  reduced  below  the  norm 
by  absorption  through  undue  friction  and  bearing  upon  it. 

A  clinical  examination  of  the  form  and  relation  of  the 
bones  in  the  very  young,  affected  with  non-rachitic  gonu- 
valgum  from  weakness,  shows  that 
enlargement  of  the  internal  condyle 
does  not  at  that  period  exist.  See 
fig.  11.  There  is  prominence  of  the 
knee  on  the  internal  aspect  ("  in- 
knee"),  but  not  increase  of  bulk, 
either  of  that  condyle  or  of  the 
neighbouring  internal  part  of  the 
tibia.  In  the  very  young  this  pro- 
minence immediately  disappears, 
when  in  the  gentlest  manner  the 
limb  is  straightened  with  the  hand. 
Gradually,  however,  during  the  per- 
sistence of  the  distortion,  and  the 
constant  strain  and  stretching  in 
walking  and  standing,  which  is  ex- 
perienced by  all  the  structures  on 
the  inner  aspect  of  the  knee  joint, 
when  the  distortion  is  not  arrested 
in  early  childhood,  some  thicken- 
ing and  deposit  in  the  structures, 
bone,  periosteum  and  ligament,  take 
place.  These  changes  may  be  the 
result  of  altered  nutrition  and  growth  of  bone  through  pro- 
longed afflux  of  blood  to  the  part  under  influence  of  strain. 

In  1842-3  (Lectures  in  'Lancet')  the  author  said, 
"  Besides  curvature  of  leg  bones  the  internal  condyle  of  the 
femur  becomes  (with  the  progress  of  the  distortion)  very  pro- 
minent, and  sometimes  disproportionately  enlarged,  whilst 


Moderate  amount  of  atonic  {non- 
rachitic) gemt-valpum  in  a 
very  young  child,  seen  from 
behind;  reduced  from  a  natu- 
ral sized  actual  tracing  from 
the  limbs,  to  shoiv  prominence 
of  the  internal  condyle,  but 
no  enlargement  of  it  in  tltis 
stage. 


26 


IN-KNEK    DISTORTION. 


Fio.  12. 


the  development  of  the  external  condyle  is  impeded."  These 
changes  are  in  some  cases  denoted  hy  the  aching  pain  and 
sense  of  weakness  complained  of  at  the  part  as  age  ad- 
vances, and  as  the  demands  upon  the  powers  of  locomotion, 
especial^  amongst  the  i)oor,  increase. 

Fig.  12  is  a  fairly  typical  example  of  a  child  who  could 
stand  and  walk  alone,  affected  with  atonic  genu-valgum  of 

both  limljs.  Compare  with  the 
above  a  case  of  moderate  knock- 
knee  of  ricket}^  origin,  in  which 
loss  of  symmetry  is  very  marked 
(fig.  3,  p.  6),  not  owing  alone  to 
the  distortion,  but  also  from  the 
marked  swelling  of  the  ends  and 
smaller  swelling  of  the  shafts. 
The  annexed  diagram  a  (p.  27),  of 
left  knock-knee,  will  afford  an  idea 
of  the  mechanical  relation  of  the 
femur  and  tibia  before  and  after 
restoration  of  form.  The  outline 
{a,  c)  is  supposed  to  represent  the 
left  femur  of  fig.  3,  and  c,  h  is 
supposed  to  represent  the  leg  or 
the  tibia  before  recovery ;  the 
dotted  outline,  ending  below  at 
d,  is  intended  to  represent  the 
leg  brought  into  a  straight  line 
with  the  trunk,  as  it  immediatel}' 
becomes  in  a  successfully  handled 
or  instrumentally  treated  case  of  well-marked  knock-knee 
of  a  very  young  child.  When  an  atonic  case,  and  occa- 
sionally a  half-cured  rickety  one,  is  gently  handled  and 
straightened  by  applying  the  palm  of  one  hand  against  the 
inside  of  the  knee,  at  c  in  the  diagram  a,  and  the  other 
hand  against  the  outer  malleolus,  at  }i  in  the  same  diagram, 


Slifilit  alonic  douhh'  hi-hnee. 


GAP   BETWEEN    FEMUR   AND    TIBIA. 


27 


Diagram  a. 


there  results — as  shown  by  the  dotted  outhne  ending  below 
at  d — a  triangular  gap  (e)  between  the  supposed  arti- 
cular surface  of  the  femur  and  the  opposing  surface  of 
the  tibia. 

The  surgeon,  when  examining  in  the  same  manner  the 
child's  living  limb,  may  feel  this  triangular  gap,  into  which, 
but  for  the  integuments,  fascia,  and  liga- 
ments, he  might  almost  introduce  the  tip 
of  his  finger.  This  gap  represents  a  space 
equal  to  the  amount  of  the  existing  defi- 
ciency in  length  of  the  external  condyle, 
and  the  corresponding  articular  facet  of 
the  tibia,  augmented  at  this  early  stage  of 
the  distortion  by  the  laxity  of  ligaments.* 

The  surgeon,  by  the  most  gentle  hand- 
ling, has  removed  all  prominence  of  the 
internal  part  of  the  knee  and  of  the  in- 
ternal condyle,  and  therefore  all  deformity  a 
has  at  once  disappeared.  The  limb  has  Diagram  of  left  hwck- 
recovered  its  natural  symmetry.  He  is  kneejmm Little,  on 
cognizant  of  an  unusual  space  between  the 
external  articular  surfaces  of  the  femur 
and  tibia,  due  to  deficiency  of  the  external 
condyle  and  to  relaxation  of  ligament  from 
the  fact  of  feeling  the  gap  between  it  and 
the  outer  part  of  the  articular  surface  of 
the  tibia,  and  because  when  holding  the 
thigh  immovable  with  one  hand  he  can 
with  the  other,  by  moving  the  leg  to  and 
fro  in  the  horizontal  plane,  recognise  an 
unnatural  "play"  in  the  knee  joint,  "wob- 
bling" ("Schlottern"),  and  is  able  at  will  to  produce  genu- 
valgum,  or  the  normal  position  and  symmetry.  This  normal 
position  is  temporarily  produced  by  him,  for  with  his  hands 
-'•  Little  :  '  Deformities  of  tlie  Human  Frame,'  1853,  j).  220. 


'Deformities,^  1853, 
p.  218 :  (a)  femur  ; 
{&)  tibia;  (c)  the  pro- 
jecting knee  joint 
of  genu -valgum; 
{d)  dotted  lines  re- 
presenting the  tibia 
placed  in  its  natu- 
ral relation ;  (e)gap 
left  on  outside  of 
the  joint,  when  tem- 
porary replacement 
is  effected. 


^8  IN-KNEE    DISTORTION. 

he  holds  the  joint  straight,  in  the  same  manner  as  he  could 
effect  straightening  in  an  anatomical  specimen  hj  placing  a 
wedge  between  the  external  condyle  and  the  opposite  part 
of  the  tibia.  It  is  possible  that  the  sm-geon,  if  he  impro- 
per 1}^  applied  adequate  force,  might  convert  the  in-knee  into 
the  opposite  distortion  (genu-extrorsum) ;  but  if  he  uses  no 
more  than  the  gentle  pressure  we  have  spoken  of,  he  will 
merely  straighten  the  limb,  and  will  be  unable  to  intro- 
duce the  tip  of  the  finger  between  the  internal  condyle 
and  tibia,  as  he  was  able  to  do  on  the  external  side  of 
the  joint. 

With  increasing  age  and  recovery  of  tone  the  looseness 
of  the  joint  in  the  extended  position  ceases,  but  the  deformity 
produced  during  the  atonic  stage  continues  (if  unattended 
to),  and  afterwards  increases  through  statical  influence.  The 
gap  also  ceases  to  exist,  but  from  clinical  observation  and 
post-mortem  anatomical  sources  of  information,  derived, 
as  will  be  shown,  from  the  labours  of  Sandifort,  Mayer,  and 
Mikulicz,  we  have  evidence  of  the  pre-existence  of  the  gap 
during  the  early  stage  (atonic),  in  the  fact  of  the  observed 
wide  space  interposed  between  the  external  condyle  and 
opposite  surface  of  the  tibia  when  the  femur  and  tibia  are 
straightened,  as  regards  one  another,  and  placed  in  their 
normal  relation.  See  figs.  13  and  14.  We  may  affirm,  also, 
from  our  therapeutic  experience  from  instrumental  treat- 
ment, by  means  of  which  we  assist  Nature  to  deposit  new 
bone  where  the  gap  from  deficiency  existed  (pp.  29,  30), 
and  from  the  effects  of  supra-condylar  osteotomy  (Macewen), 
which  gives  length  to  the  limb  on  its  outer  aspect,  whereby 
the  genu-valgum  is  cured,  that  a  wedge-like  portion  of 
bone  has  been  substituted,  supplying  in  the  shaft  of  the 
femur  the  deficiency  previously  existing  at  the  outer 
condyle. 

This  gap  (fig.  20)  is  a  measure  of  the  amount  of  bony 
deposit  which,  during  curative  treatment  by  use  of  mecha- 


DIMINUTION    OF    EXTERNAL    CONDYLE.  29 

nical  splints  or  other  appliances,  the  orthopaedic  surgeon 
attracts  to  the  external  condyle  and  opposite  surface  of  the 
tibia,  i.  e.,  renders  deposit  of  bone  possible  during  the  pro- 
gress of  growth  by  relieving  the  outer  condyle  and  tibia  from 
the  pressure  it  undergoes  when  walking  is  permitted,  so  long 
as  the  limb  has  the  form  of  knock-knee,  and  thus  brings 
about  a  lengthening  of  the  external  condyle  and  heighten- 
ing of  the  external  part  of  the  articular  surface  of  the  tibia, 
and,  together  with  recovered  tone  in  the  fibrous  tissues, 
effects  a  cure.  This  cure  consists  of  no  temporary  replace- 
ment of  parts,  but  is  an  instance  of  the  true  art  of  medicine, 
that  of  being  the  "interpreter  and  helper  of  Nature."  For 
over  a  generation  we  have  watched  with  the  deepest  interest 
the  repetition  of  this  phenomenon  of  nature's  masonry  in 
repairing  an  arrested  development  of  bone  in  the  limb  of 
the  young  child,  and  in  adolescents,  at  the  oppressed  ex- 
ternal side  of  the  femur  and  tibia  when  the  shafts  have 
been  relieved  from  undue  pressure  by  proper  interference. 

This  therapeutic  practice  proved,  as  was  expected,  that 
when  released  from  undue  pressure  the  external  condyle 
and  neighbouring  part  of  the  shaft  of  the  tibia  would, 
at  least  in  the  young  child,  grow  into  and  fill  up  the  space 
provided  by  the  treatment  for  it ;  in  short,  that  the  femur 
and  corresponding  part  of  the  tibia  in  the  progress  of  growth 
and  development,  when  released  from  accidental  obstacles, 
would  revert  to  the  natural  physiological  type.  C.  Hueter, 
speaking  in  1877  of  his  method  of  successful  treatment  of 
these  cases,*  which  will  be  described  in  the  section  on 
treatment,  says : — "  I  reckoned  on  the  disposition  of  the 
cartilaginous  tissue  in  rachitic  cases  to  exuberant  expansive 
growth,  and  fancied  that  in  rachitic  children  affected  with 
genu-valgum  the  undue  depressions  in  the  articular  surfaces 
would  rapidly  fill  up  (by  cartilaginous  cell  proliferation),  as 
soon  as,  for  a  short  time,  the  undue  weight  could  be  removed 
*  O/A  clt.,  p.  264. 


30  IN-KNEE    DISTORTION. 

during  standing  and  walking."  We  have  had  ample  expe- 
rience that  the  same  Nature's  mode  of  cure  comes  to  pass 
in  other  than  rachitic  cases.* 

In  a  course  of  lectures,  published  in  the  '  Lancet '  in 
1842-3,  we  described  this  aduptniioii  of  the  articular  sur- 
faces to  the  change  of  their  relation  effected  during  the 
treatment.  In  the  work  on  'Deformities,'  already  quoted 
(see  note,  pp.  216 — 218),  when  speaking  of  a  severe  case, 
treated  in  a  young  adult  female  by  instrumental  means,  it 
was  shown  that  even  in  such  a  case  the  gap  caused  by  defi- 
ciency on  the  external  parts  of  the  articular  surfaces,  when 
the  tibia  had  been  brought  into  a  straight  line  with  the 
trunk,  may  become  filled  up.  At  that  time  the  author 
wrote: — "It  was  an  interesting  question  whether,  as  the 
patient  had  reached  full  growth,  the  articular  surfaces  of 
the  femur  and  tibia  would  adapt  themselves  to  their  altered 
relation.  Confiding  in  the  extraordinary  powers  of  adapta- 
tion manifested  by  articular  surfaces  during  treatment  of 
severe  club-foot,  I  trusted  that,  although  the  growth  of  the 
body  was  completed,  this  beneficial  result  would  in  time 
take  place,  if  the  x^sition  of  the  legs  in  the  perpendicular 
line  could  by  mechanical  aid  be  preserved.  This  result  did 
occur.  For  several  years  afterwards  we  received  an  occa- 
sional visit  from  this  patient.  81ie  ultimately  lost  all  trace 
of  genu- valgum,"  and  walked  two  or  three  miles,  needing  no 
mechanical  support.  She  would  have  walked  longer  dis- 
tances if  she  had  not  also  sufiered  from  scoliosis.  Notwith- 
standing the  publication  of  these  experiences  a  generation 
ago,  a  justly  distinguished  surgeon  has  written  as  to  this 
matter,  that  "  he  had  heard  it  said  that  cases  could  be 
cured  by  mechanical  means,  but  he  had  had  no  exj)erience 
of  it." 

*  Tlie  reader  may  be  here  remiuded  that  C.  Hiieter,  in  ray  opinion 
erroneously,  beheves  that  all  ca&es  of  iu-knee  in  children  are  of  rachitic 
origin. 


DIMINUTION    OF    EXTERNAL    CONDYLE.  31 

Enough  has  been  stated  to  justify  the  formal  assertion 
that  deficiency  in  length  or  arrested  development  through 
pressure  of  the  external  condylar  part  of  the  femur,  and  not 
an  excessive  length  of  the  internal  condylar  part,  is  the 
primary  characteristic  anatomical  feature  of  knock-knee  in 
the  child's  earliest  years,  as  announced  by  us  so  long  ago 
as  1842.  Several  surgeons,  who  have  recently  written  on 
genu-valgum,  have  based  their  respective  operations  per- 
formed for  its  relief  upon  the  opinion  that  the  essential 
anatomical  feature  of  the  complaint  is  an  enlargement  of 
the  internal  condyle,  having  ignored  the  fact  of  shortening 
of  the  external  one. 

Neither  Jules  Guerin*  nor  Bouvier,t  who  have  ably 
written  on  rickets,  have  distinguished  the  atonic  or  idiopathic 
in-knee  cases  from  rickety  ones. 

Speaking,  however,  as  to  spinal  curvature,  and  on  the 
states  of  it  to  be  distinguished  from  rachitis,  Bouvier  (p.  269) 
remarks :  "La  deviation  laterale  du  rachis  peut  dependre 
du  rachitisme,  mais  elle  se  rencontre  tres  souvent  aussi  [we 
should  have  said  much  more  frequently]  sans  le  moindre 

ramolissemeiit  des  os,  meme  anterieur  a  la  deformation 

J'ecarte  toutes  ces  lesions  qui  ont  plus  ou  moins  d'affinite 
avec  le  rachitisme,  pour  ne  m'occuper  que  de  la  maladie  que 
Glisson  a  decrite  de  main  de  maitre." 

Bouvier  admits  a  first  period  in  rickets,  which  he  terms 
that  of  atrophy,  combined  with  increased  flexibility,  fra- 
gility, and  curvature,  but  did  not  notice  that  deviation  of 
knee  inwards  is  a  weakness  of  the  joint,  often  without  cur- 
vature or  enlargement  of  epiphyses. 

Dr.  Newton  M.  Shafi"er,+  of  New  York,  has  recognised 

*  '  Vues  Generales  sur  les  Difformites  du  Sj'stenie  osaeux,'  Paris, 
1840. 

f  '  Lec^ons  cliuiques  sur  les  Maladies  Clironiques  de  I'Appareil 
Locomoteur,'  Paris,  1858. 

I  On  '  Knock-knee  and  Bow-legs,'  New  Yoi'k,  1881. 


32  IN-KNEE    DISTORTION. 

that  there  are  cases  he  can  hardly  attribute  to  rickets.  He 
saj^s  {op.  cit.,  p.  7),  iu  relation  to  the  disorder  of  nutrition  in 
this  distortion:  "I  wish  I  could  satisfactorily  answer  the 
query  which  here  presents,  and  say  what  is  the  cause  of  this 
disturbance  of  nutrition.  Is  it  a  process  of  mal-nutrition 
affecting  the  system  generally,  but  finding  its  principal  ex- 
pression at  the  knee  joint  ?  "  We  have  shown  that,  although 
most  frequent  at  the  knee  joint,  the  atonic  condition  of 
fibrous  and  osseous  structures  in  question  is  not  confined 
to  the  knee  joint,  for  we  find  it  in  scoliosis,  and  in  the 
weakness  termed  in-ankle,  which  in  the  advanced  stage  is 
termed  by  us  non-rachitic  flat-foot.  Dr.  Shaffer  proceeds 
to  say  :  "  Can  we  make  the  generally  accepted  definition  of 
rickets  apply  to  all  the  cases  that  are  found  in  these  localised 
expressions  of  osseous  deformity  seen  in  knock-knee  ?  If 
so,  why  is  it  so  localised  ?  for  knock-knee  frequently  presents 
as  a  strictly- speaking  unilateral  deformity,  and  affects  only 
one  bone  or  one  articulation,  Kickets  is  a  constitutional 
disease,  and  is  characterised  by  some  conditions  which  are 
not  always  found  in  knock-knee."  .  .  .  .  "  There  is  certainly 
something  which  remains  to  be  explained  regarding  the 
etiology  of  knock-knee  ;  a  something  which  time  and  investi- 
gation only  can  develop."  .  .  .  .  "  If  we  apply  the  answers 
which  must  be  made  to  these  questions  to  the  conditions 
found  in  the  knee  joint  in  genu-valgum,  we  are  led  far  away 
from  the  ordinarily  accepted  definition  of  rachitis."  .... 
"  If  we  recognise  that  these  changes  in  the  knee  (knock- 
knee),  whether  inflammatory*  or  trophic,  are  not  always 
associated  with  rickets,  we  have,  I  firmly  believe,  taken  a 
step  in  the  right  direction."  ....  "Ligamentous  relaxation, 
2)lus  the  predisposing  cause,  whatever  it  may  be,  is  sure  to 
result  in  true  progressive  genu-valgum"  if  unattended  to. 

■■•  We  liave  pointed  out  (p.  3)  tliat  pain  or  inflammation  in  either 
atonic  or  in  rickety  in-knee  only  occurs  after  undue  strain  in  walking, 
or  as  tlie  result  of  a  fall. 


CONCURRENCE    IN    AUTHOR' S    VIEWS.  33 

Whilst  this  sheet  has  heen  passing  through  the  press, 
the  *  Transactions  of  the  International  Medical  Congress  ' 
(London,  1881)  have  come  to  hand.  It  is  satisfactory  to 
find  that  several  observers  concur  in  the  view  published  in 
these  pages  that  several  varieties  of  in-lmee  distortion  exist. 
Thus  Mr.  H.  F.  Baker,  during  a  five  years'  residence  at  the 
Eoyal  Orthopaedic  Hospital,  London,  watched  nearly  800 
cases  of  genu-valgum,  and  in  nearly  all  of  them  the  dis- 
tortion""took  place  at  the  joint  itself,  and  was  quite  inde- 
pendent of  the  bone  curvatures. 

M.  Jules  Guerin  (vol.  iv.  p.  201)  describes  four  forms, 
and  has  noticed  the  "  gap  "  described  by  us,  p.  27,  for  he 
remarks  that  "  redressement"  leaves  a  wedge-shaped  in- 
terval capable  of  holding  the  finger,  but  which  diminishes 
from  without  inwards."  On  the  contrary,  speakers  at  the 
Congress,  as  at  the  Pathological  Society's  discussion,  1880, 
attribute  almost  every  case  of  in-knee  to  rickets,  they 
having  fallen  into  the  same  error  into  which  all  fall  who 
have  only  a  comparatively  short  experience  of  this  dis- 
tortion, as  we  ourselves  had  when  we  wrote  on  this  subject 
over  a  generation  ago. 

Dr.  Shaffer*  is  an  able  and  watchful  observer,  and  has 
largely  shed  light  over  several  distortions,  thanks,  in  part, 
to  the  opportunities  afforded  him  as  Surgeon  to  the  New 
York  Dispensary  and  Orthopaedic  Hospital.  Another  step 
in  the  direction  he  has  set  out  upon,  will  lead  him,  we  be- 
lieve, to  the  recognition  of  the  accuracy  of  the  views  we  are 
developing  in  this  work,  that  atonic  or  idiopathic  in-knee 
deviation  should  be  entirely  dissociated  nosologically  from 
rachitis,  and  that  it  originates  during  the  growing  age  of 
the  individual,  but  especially  often  during  the  most  active 
periods  of  growth,  viz.,  during  the  first  years  of  life,  at  or 

*  Dr.  Shaffer's  memoir,  tlie  title  of  which  we  have  given,  will 
well  repay  the  reader  who  desires  fm-ther  to  investigate  the  pathology 
of  in-knee. 

F 


34  IN-KNKE    DISTOKTION. 

about  the  age  when  heaUhj^  children  first  walk,  and  during 
the  accelerated  growth  which  accompanies  advancing  pu- 
berty. The  failing  to  recognise  infantile  non-rachitic,  as 
well  as  rachitic,  in-knee,  has  probably  been  caused  by  the 
fact  that  either  condition  may  arise  in  infaiic}^  and  because 
'  both  the  (Ustoytio)is  continue  until  or  after  puberty. 

The  fact  of  the  origin  of  atonic  or  idiopathic  in-knec 
during  puberty  has  increased  the  difficulty.  It  has  required 
of  us  many  years  of  observation,  and  larger  public  and 
private  opportunities,  to  surmount  the  difficulties  and  doubts 
which,  for  example,  Shatter  describes  himself  as  entertain- 
ing. Authors  have  overlooked  the  emphatic  statement  of 
Jules  Guerin  :  "  Le  rachitisme  est  exclusivement  une  maladie 
de  I'enfance."* 

The  fact  in  the  history  of  infantile  rachitic  in-knee,  and 
of  curvatures  of  the  thigh  and  leg  bones,  vi.z.,  that  these  are 
sometimes  met  with  at  birth,  appears  at  first  view  to  nega- 
tive our  opinion  that  all  cases  are  influenced  by  gravity  as 
an  external  causatory  agent.  It  is  certain  that  wdtliin  the 
womb  gravity  in  its  ordinary  sense  cannot  affect  the  foetus 
in  the  manner  in  which  it  aft'ects  the  infant  when,  at  about 
nine  months  to  a  year  old,  it  is  attempting  to  walk. 

Gravity  in  the  ivfant  labouring  under  weakened  passive 
structures  of  the  organs  of  locomotion  is  an  external  deter- 
mining agent.  If  the  foetus  within  the  womb  be  affected 
with  the  constitutional  disease  termed  rickets,  so  that  the 
ligaments  and  long  bones  of  the  lower  limbs  have  less  than 
their  proper  development  as  to  firmness  and  power  of  re- 
sistance to  the  external  forces  to  which  in  the  w^omb  they 
are  exposed,  they  might  be  expected  to  jaeld  to  such  ex- 
ternal influences  as  they  may  be  exposed  to  within  the 
womb,  as  readily  as  infants  do  without  the  womb.  The 
external  influences  in  question  are  pressure  against  the 

"-■'  '  Menu  die  sur  les  cliaractcres  gencraux  du  Rachitisme,'  Paris, 
1880,  p.  '11. 


INFLUENCE    OF    CAUSES    WITHIN    THE    WOMR.  85 

walls  of  the  uterus  and  the  parietes  of  the  abdomen,  the 
vertebral  column  and  pelvis  of  the  mother. 

In  the  normal  stage  of  the  foetal  development  we  l<now 
that  the  organs  of  the  mother  are  so  adapted,  the  Liq. 
Amnii  is  so  abundant,  and  the  head,  trunk  and  limbs  of  the 
foetus  are  so  arranged,  that  at  birth  no  signs  of  too  close 
packing  or  of  distortion  are  perceptible.  Obstetricians  have, 
it  is  true,  noted  as  an  occasional  circumstance  that  the  hips 
and  knees  of  the  new-born  child  have  been  found  unduly 
stiff  and  slightly  contracted,  a  condition  which  we  know 
spontaneously  subsides,  or  is  cured  within  the  month  by 
the  nurse's  rubbing.  Other  observers  have  said  that  this 
contraction  at  birth  exists  in  all  cases. 

At  any  rate,  it  may  be  assumed  that  in  the  uterus,  the 
foetus — with  the  placenta,  the  membranes,  and  fluid — has 
ordinarily  no  more  space  at  disposal  than  is  necessary,  and 
we  know  that  sometimes  space  is  deficient.  We  see,  there- 
fore, that  the  foetus  in  utero,  besides  being  liable  to  rickets, 
to  accidental  fractures,  and  fractures  from  action  of  its  own 
muscles,  is  exposed  to  such  mechanical  forces  external  to 
its  own  organism  as  would  be  likely  to  occasion  curvatures 
of  the  long  bones,  and  not  improbably  genu-valgum,  in  the 
few  cases  in  which  it  has  been  met  with  as  a  congenital 
affection. 

It  should  also  be  here  remarked,  that  amongst  the 
causes  internal,  both  to  the  foetal  and  infantile  organisms, 
which  are  capable  of  thus  modifying  the  form  of  the  joints 
and  long  bones,  a  disturbed  spasmodic  action  of  the  muscles 
upon  them  should  be  reckoned.  (Extraction  musculaire  of 
Guerin.) 

Von  Ammon*  gives  drawings  of  several  cases  of  consi- 
derable congenital  genu-valgum.  But  these  appear  to  be 
ordinary  non-congenital  genu-valgum,  of  which  they  have 

''''  '  Die  angeborenen   Cliirurgisclien   Kranklieiteu,'    Berlin,    1842, 
Tab.  xxvii. 


36  IN-KNEE    DISTORTION. 

all  the  charactevs,  Exporience  teaches  that  the  statements 
of  growii-iip  lads  and  adults  as  to  congenital  origm  of  de- 
'formities  cannot  be  conclusively  relied  upon.  We  have 
never  met  with,  during  infancy,  a  marked  congenital  genu- 
valgum.  We  do  not,  however,  dispute  that  foetuses  affected 
with  a  series  of  distortions  have  also  presented  in-knee  de- 
viation from  spasmodic  causes.* 

When  in-knee  deviation  presents  itself  in  relaxed,  weakly 
children,  who  have  neither  walked  nor  have  been  prema- 
turely incited  and  assisted  to  try  to  stand  and  walk,  the 
influence  of  the  weight  of  the  upper  parts  of  the  frame  upon 
the  weak  knees  might  be  rejected.  It  should,  however,  be 
remembered  that  long  before  a  suspicion  of  weakness  or 
backwardness  in  using  the  lower  limbs  has  arisen,  the  child, 
as  is  usual  and  proper,  has  been  at  least  accustomed  to  try 
and  walk  up  the  nurse's  lap.  For  a  similar  reason  it  might 
be  objected  that  in  acute  and  chronic  knee  joint  inflamma- 
tion, in  which  after  a  time  knee  inversion  is  apt  to  occur, 
gravit}^  is  less  likely  to  have  become  the  determining  cause 
of  the  morbid  inversion.  To  this  objection  it  may  be  re- 
marked that  in  the  majority  of  cases,  when  the  acute  stage 
of  disease  has  subsided,  the  patient  too  frequentl}^  attempts 
prematurely  to  use  the  part,  and  it  is  in  the  later  stages 
that  the  morbid  inversion  is  noticed.  Moreover,  as  may  be 
read  hereafter,  the  experience  of  the  influence  of  gravity  in 
genu-valgum  from  local  disease,  as  in  the  other  forms,  does 
not  exclude,  as  we  have  already  shown,  the  co-operation  of 
muscular  contraction,  when  by  the  effect  of  disease  and 
effusion  upon  the  ligaments,  which  in  health  bind  together 
and  support  the  articular  ends  of  the  femur  and  tibia,  they 
are  distended  and  loosened,  the  joint  becomes  a  jDrey  not 
only  to  mechanical  external  causes  (gravity  and  evil  posi- 
tion), but  to  the  action  of  muscles. 

We  have  evidence  that  even  a  perfectly  sound  knee  may 
■■'  '  Qiiivres  (in  Docteur  Jules  Guurin,'  Livraison  ler,  Paris,  1880. 


ITS    PEODUCTION   IN    A    SOUND    LIMB.  37 

become  affected  with  genu-valgum.  Thus  it  is  a  frequent 
occurrence  that  a  healthy  person  born  with  a  congenital 
defect  of  one  lower  extremity,  or  a  person  who  has  become 
stricken  with  slight  general  infantile  paralysis  of  one  lower 
extremity,  or  who  has  met  with  an  accidental  injury  of  it, 
from  all  which  causes  a  weakening  of  the  member  results, 
and  that,  whether  or  no,  it  becomes  affected  with  genu-valgum, 
it  (the  defective  limb)  is  at  all  events  unable  to  do  its  full 
share  of  work  in  the  labour  of  locomotion.  The  lame  leg 
makes  as  many  steps  as  the  sound  one,  but  the  individual, 
after  each  step,  does  not  rest  so  long  upon  it  as  he  does 
upon  the  sound  limb;  hence  the  "quick"  halting,  un- 
rhythmical gait  of  many  lame  persons.  Besides  which,  the 
labour  of  propelling  the  body  onwards  falls  unequally  upon 
the  two  limbs.  The  lame  one  may  not  expend  one-fourth 
of  the  energy  and  force  in  the  act  of  propulsion  and  move- 
ment in  locomotion  which  the  sound  limb  does.  The  result 
is,  that  after  a  few  months  or  years,  the  sound  limb  of  the 
most  healthy  individual  may  give  way  at  the  knee,  present- 
ing a  distinct  degree  of  genu-valgum,  accompanied  for  the 
most  part  with  a  corresponding  degree  of  flat-foot  (spurious 
valgus) . 

We  learn  from  this  fact,  and  others,  of  daily  occurrence 
in  children,  adolescents,  and  adults,  that  the  human  lower 
extremity — i.  e.,  its  bones,  ligaments,  and  muscles — is  con- 
structed only  for  a  suitable  maximum  amount  of  work,  even 
under  the  best  conditions  of  climate,  food,  alternation  of 
rest  and  fatigue.  To  repeat,  we  conclude  that  the  limb  of 
a  growing  infant,  who  came  into  the  world  without  cog- 
nisable defect,  and  had  been  supplied  with  the  best  motherly 
and  hygienic  surroundings,  is  only  provided  with  the  energy 
and  force  suitable  for  the  maximum  work  the  limb  of  an 
average  robust  infant  has  to  perform. 

We  cannot  be  surprised,  then,  that  the  absence  of  breast- 
milk,  and  the  substitution  for  it  of  a  watery,  poor,  or  un- 


38  IN-KNEE    DISTORTION. 

suitable  diet,  the  nntrition  of  the  infant  should  be  so  impaired 
that,  without  the  institution  of  a  specific  disease — rachitis — 
the  fibrous  tissues  should  so  lose  in  strength  and  toughness 
that  the  important  knee  joint  is  incapable  of  withstanding 
the  strain  of  the  comparatively  light  oftice  it  has  at  that 
age  to  perform,  and  that  it  should  yield  in  the  direction 
which  the  anatomical  arrangement  favours. 

It  has  long  been  laid  down  that  "there  exists  no  aberra- 
tion of  form  without  alteration  of  structure."  *  At  pp.  15,  21, 
we  have  touched  upon  the  question  of  the  morbid  anatomy 
of  the  fibrous  structures  in  hand-fed  infants  affected  with 
in-knee.  Fortunately  these  cases  recover  so  quickly  during 
early  infancy,  by  two  or  three  months'  employment  of  suit- 
able diet,  hygienic  influences,  and  attention  to  topical  re- 
medies (see  treatment  of  in-knee),  that  no  opportunity  has 
been  afforded  us  for  anatomical  research.  We  have  had  to 
content  ourselves  with  a  clinical  diagnosis  between  the  non- 
rachitic and  the  rachitic  forms. 

It  will  be  remembered  that  we  have  dwelt  upon  the  fact 
that  in  atonic  in-knee  the  ligaments  snd  muscles  are  re- 
laxed in  the  early  stage,  but  become  tightened  up  in  the 
adolescent  and  confirmed  stage,  through  their  adaptation 
to  the  persistent  deformity.  In  fact,  it  is  found  in  the  con- 
firmed stage  that  the  knee  resists  the  efforts  of  the  surgeon's 
hands  to  restore  it  to  the  natural  shape. 

We  consider  that  in  a  confirmed  case,  whether  originally 
idiopathic,  atonic,  or  rickety,  the  internal  lateral  ligament 
is  only  so  much  stretched  out  as  is  required  for  accommoda- 
tion to  the  displacement  which  the  inner  part  of  the  knee 
undergoes  in  consequence  of  the  abduction  of  the  leg. 

It  will  be  noticed  farther  on  that  Mayer  described  his 

having  found  after  death  all  the  knee  ligaments  relaxed  in 

an  atonic  or  idiopathic  case,  aged  sixteen,  of  several  years' 

duration.    He  was  not  aware  of  the  true  explanation  of  this 

■■'•  Trinquier :  '  Gazette  Medicale  tie  Moutpelier,'  January,  1844. 


UNDUE    LOOSENESS    OE    JOINT    IN    ADOLESCENTS.  39 

fact.  He  narrates  that  the  case  had  previously  been  under 
his  mechanical  treatment.  We  have  no  doubt  that  it  had 
been  played  fast-and-loose  with,  and  that  the  looseness  was 
not  a  character  of  the  deformity  at  that  stage,  but  an  arti- 
ficial result  of  the  treatment.  See  a  similar  case  of  an 
adult  female  treated  by  us  (p.  30). 

Mayer's  case  in  question  illustrates  the  remark  we  have 
already  made  that  surgeons  have  often  failed  to  discriminate 
the  difference  of  condition  of  a  given  case  of  distortion  in 
its  early  and  in  its  latest  stage,  and,  we  may  add,  over- 
looked the  share  which  incomplete  or  improper  treatment 
has  artificially  produced. 

We  are  led  to  dwell  here  on  the  infiuence  of  lengthened 
or  shortened  ligaments  in  genu-valgum,  because,  soon  after 
Mayer's  writings  appeared,  an  important  addition  to  the 
knowledge  of  the  morbid  anatomy  of  the  ligaments  and 
bones  was  made  by  Professor  Linhart,  a  fellow-townsman 
of  Mayer.* 

Science  is  indebted  to  Mayer  and  Linhart  for  morbid 
anatomy  observations  in  adult  cases.  Neither  of  these 
pathologists  dissected  young  cases,  or  surmised  that  the 
conditions  might  be  different  in  the  first  stages  of  the  com- 
plaint, especially  in  early  childhood.  In  opposition  to  those 
who  believed  that  the  internal  lateral  ligament  was  relaxed 
and  weakened,  and  thus  favoured  the  production  of  knee 
inversion,  Linhart  stated  that  this  ligament  was  thickened 
to  a  remarkable  extent,  so  that,  as  he  writes,  "those  sur- 
geons who  are  disposed  to  regard  facts  from  a  teleological 
side  Avould  rejoice  that  Nature  has  done  so  much  to  prevent 
internal  luxation  (projection)  of  the  femur."  f 

*  '  Ueber  Erschlaffung,  Atonie  cler  selmigen  Gewebe,'  von  Dr.  "W. 
Linhart.  '  Vierteljalirsclirift  fiir  die  praktisclie  Heilknnde,'  Prague, 
1859. 

f  As  to  genu-valgum,  Linliart  errs  in  using  tlie  expression  "  luxa- 
tion."   The  insertion  of  the  word  "projection"  is  a  correction  of  ours. 


40  IN-KNEE    DISTORTION. 

The  undue  tension  and  stretching  of  this  ligament  is  apt 
to  be  accompanied  with  hj^peraemia.  This  "ubi  irritation  ibi 
affluxus"  leads  to  augmented  nutrition — hypertrophy.  If 
the  strain  upon  the  ligament  be  not  arrested  by  treatment, 
the  hypersemia  may  lead  to  inflammation  ;  experience  of  the 
worst  adult  cases,  however,  shows  that  the  stage  of  inflam- 
mation in  ordinary  atonic  and  rachitic  cases  is  not  reached, 
unless  other  causes,  such  as  a  fall  or  rheumatism,  be 
applied. 

From  our  own  clinical  observations  in  atonic  infantile 
non-rachitic  cases,  especially  from  the  before  described 
(p.  27)  lateral  mobility  in  them,  we  consider  it  to  be  proved 
that  all  the  fibrous  structures — lateral,  capsular,  inter- 
articular  ligaments,  and  the  muscles — are  relaxed,  so  that 
they  abnormally  yield  beneath  the  influence  of  gravity,  and 
thus  the  distortion  is  produced.  When,  however,  the  nutri- 
tion of  the  individual  has  improved,  the  relaxation  of  these 
structures  is  replaced  by  a  natural  tonic  condition  of  them, 
so  that  the  articulation  loses  its  previous  mobility,  and 
becomes  more  or  less  set  when  the  knee  is  extended  in  the 
deformed  shape,  owing  to  changes  in  the  component  parts 
of  the  joint  which  the  progress  of  the  disorder  produces. 

The  subject  of  tone  of  tissues,  and  its  deficiency,  has 
little  engaged  the  attention  of  pathologists,  except  in  regard 
to  muscles.  Any  aberration  of  innervation  of  these,  con- 
nected with  nerve  supply  from  the  nerve  centres,  is  either 
spasm,  paralysis,  or  loss  of  power  of  co-ordination.  We 
consider  the  tone  proper  to  a  healthy  muscle  to  be  that 
condition  which  results  from  proper  nutrition  and  proper 
exercise  of  it.  A  deficiency  of  tone  of  muscle  arises  from 
defective  nutrition  and  want  of  proper  exercise.  In  like 
manner  we  believe  that  other  structures — the  ligaments, 
fasciae,  and  even  the  skin — are  kept  in  a  state  of  tone  when 
the  nutrition  and  the  general  hygiene  are  perfect,  and  lose 
tone  when  nutrition  and  hygiene  are  imperfect. 


CURVATURE    IN    THE    FEMORAL    DIAPHYSIS.  41 

Further  on  we  shall  adduce  other  evidence,  which  has 
led  us  to  the  conclusion  that  the  largest  number  of  cases  of 
in-knee  are  due  to  atonic  causes,  and  not  to  rickets.  Atonic 
in-knee  appears  to  us  to  present  characters  entirely  different 
from  rickets.  We  have  asked  ourselves  whether  atonic  in- 
knee  may  be  the  earliest  stage  of  rickets.  We  have  put  this 
question  to  ourselves  from  our  search  after  pathological 
truth,  and  out  of  respect  to  the  number  of  able  men  who 
have  preceded  us,  who  have,  from  our  own  point  of  view, 
failed  to  discriminate  between  infantile  and  atonic  knock- 
knee,  which  occurs  both  as  an  adolescent  affection  and 
rachitic  knock-knee,  which  is  also  an  infantile  disease,  but 
is  one  which  is  exclusively  infantile. 

Linhart,  in  the  single  case,  already  alluded  to,  found 
the  external  lateral  ligament  not  tense  or  contracted,  but 
puckered  up  in  its  sheath  in  a  wavy  manner.*  He  found  the 
crucial  ligaments  normal,  and  was  the  first  to  mention  the 
finding  in  an  adult  case  a  curvature  of  the  lower  part  of  the 
diaphysis  of  the  femur,  the  convexity  of  which  was  directed 
inwards.  "  It  was  not  an  abrupt  sudden  bend  (keine  knick- 
ung),  but  a  considerable  bow  of  the  whole  lowest  third  of 
the  bone."  This  is  the  curvature  in  the  femoral  diaphysis, 
since  so  much  dwelt  upon,  as  will  be  seen,  by  Mikulicz  and 
Macewen,  as  if  it  were  certain  that  it  is  an  invariable  con- 
dition, they  not  having  discovered  the  existence  of  non- 
rachitic forms.  Linhart  recognised  the  importance  of  this 
twist  in  the  femur,  even  in  cases  in  which  the  difference  in 
the  length  of  the  condyles  was  but  slight.  He  states  that 
he  has  observed  this  particular  twist  "in  the  living,  and 
not  unfrequently  in  cases  which  were  congenital,  or  those 
of  young  children."  The  use  of  the  preposition  "  or  "  in  the 
last  sentence  seems  to  signify  that,  according  to  him,  all 

*  Oj}.  cit.,  p.  90.  Linliart's  words  are :  "  Dieses  Band  nun  fand 
ich  in  einem  Falle  innerhalb  seiner  Scheide  wellenformig  gekrximmt, 
also  ''im  Gegensatze  zu  Spanming)  ersclilafft." 

G 


42  IN-KNEE    DISTORTION. 

infantile  cases  are  congenital,  -wliich  is  only  true  of  rickety 
hereditary  cases. 

Mayer  and  Linbart  mention  the  not  infrequent  occur- 
rence of  a  ivohhlinfi  (Schlottern)  looseness  of  the  joint ;  and 
in  the  worst  stage  of  in-knee  Mayer  distinctly  states  that 
the  case  in  which  he  observed  this  symptom  was  a  severe 
adolescent  one,  in  which,  as  we  have  already  stated,  instru- 
mental treatment  had  been  long  ineffectually  employed.  As 
Linbart  speaks  of  this  s^ymptom  as  occurring  in  the  worst 
stage  of  in-knee,  we  may  confidently  assume  that  he  refers 
to  adolescent  or  adult  cases,  because  the  worst  stage  is 
never  reached  before  advanced  adolescence  or  adult  age. 
We  have  never  seen  this  symptom  in  the  adolescent  or 
adult,  except  as  a  consequence  of  defective,  interrupted,  or 
non-continuous  use  of  mechanical  means  (p.  39).  The 
undue  lateral  mobility  of  children,  aged  twelve  or  fifteen 
months  to  two  years,  especially  of  those  who  have  only 
walked  a  few  weeks,  is  more  remarkable,  when  the  actual 
distortion  is  comparatively  very  slight,  than  in  older  chil- 
dren, in  whom  the  distortion  is  more  pronounced.  Linbart 
has  described,  under  the  words,  "atrophy*  of  the  external 
condyle  of  the  femur  and  oj)posite  external  part  of  the 
tibia,"  the  condition  of  things  which  we  described  as  the 
most  essential  abnormal  anatomical  peculiarity  in  advanced 
genu-valgum,  in  '  Deformities  of  the  Human  Frame,'  1853, 
p.  218. f 

In  these  cases  Linhart  found  the  ligaments  unchanged, 
— neither  softened  nor  attenuated,  but,  on  the  contrary, 
often  tougher  and  stronger  (derber). 

-■'-  Instead  of  the  word  "  atrophy,"  we  have  expressed  the  wasting 
of  the  external  bony  parts  of  the  joint  by  the  terms — compression, 
deterioration,  and  absorption. 

f  Mayer  and  Linhart  were  the  fii'st  who,  as  far  as  we  know,  fol- 
lowed lis  in  regarding  the  damage  to  the  external  portions  of  the  joint 
as  of  primary  importance,  compared  with  that  of  the  morbid  increase 
of  the  internal  condj'lar  parts. 


UNDUE    LOOSENESS    OF    IN-KNEE.  4B 

So  little  attention  had,  until  recently,  been  paid  to  the 
morbid  anatomy  of  deformities,  except  by  orthopaedic  sur- 
geons and  physicians,  that  Kokitansky,  '  Manual  of  Pathol. 
Anatomy,'  edit.  1849  to  1854,  Sydenham  Soc.  Translations, 
does  not  even  mention  the  morbid  anatomy  of  congenital 
club-foot,  or  of  in-knee. 

J.  Cruvelhier  ('Anatomie  Pathologique  du  Corps  Hu- 
main,'  Paris,  1829-39)  appears  equally  silent  as  to  genu- 
valgum ;  and  so  are  the  Transactions  of  the  London  Patho- 
logical Society,  published  previously  to  1881. 

It  is  only  since  the  introduction  of  tenotomy  that  the 
attention  of  the  pathologist  has  been  directed  to  the  morbid 
anatomy  of  knock-knee,  consequently  illustrative  specimens 
are  rare  in  anatomical  cabinets.  Our  knowledge  of  the 
subject  was  formerly  mainly  confined  to  clinical  observa- 
tion. We  were  thus  enabled  to  show  that,  whatever  the 
primary  etiological  influence  might  be,  and  we  then  believed 
that  the  majority  of  cases  of  genu-valgum  were  of  rickety 
origin,  the  mechanical  changes  of  relation  of  the  articular 
portions  of  the  thigh  and  leg  bones  which  ensue  were  iden- 
tical. Formerly  we  were  able  to  discover  in  medical  literature 
only  one  anatomical  observation  and  description  of  the  phy- 
sical changes  in  form  undergone  by  the  knee  bones  in  genu- 
valgum,  that  of  Sandifort,  though  not  so  designated  by  him, 
in  his  *  Museum  Anatomicum,'  vol.  iv.,  pi.  29,  which  is  here 
reproduced.     (See  fig.  13.) 

Sandifort  attributes  this  example  of  genu-valgum  to 
"hydrops  articuli,"  from  which  the  softening  and  subse- 
quent hardening  of  the  bones  may  possibly  have  proceeded ; 
but  his  description  corresponds  with  advanced  rachitic 
genu-valgum.  He  says: — "Forma  nimirum  ossium,  ubi 
articulationem  componunt,  maxime  est  mutata ;  seque  ac 
si  haec  ossium  extrema  in  prima  morbi  periodo,  quando 
emollita  fuisse  videntur,  graviditate  corporis  compressa, 
prseternaturalem  banc  acquisiverint  tiguram,  quam  dein. 


44 


IN-KNEE    DISTORTION. 


cluritie  ossis  rursiis  aucta,  retiniierint,  dum  post  illud 
tempus'  margiiium  siiperficierum  articularium  excrescentiae 
procul  dubio  exortae  sunt." 


Fig.  1H. 


Fig.  U. 


Fig.  13. — lllustratiun  vj  the  change  of  J'onii  and  directiun  of  tlie  articular 
surfaces  and  sliafts  of  the  femur  and  tibia,  which  maij  ultimately  emue  in  what 
we  believe  was  rheumatic  genu-vahjum,  from  Saiidifort.  'The  extreme  obliquity 
of  the  articular  stnfaceti  is  apparent,  as  well  as  the  thrustinr/  or  crushing  itp- 
wards,  and  absorption  at  the  expense  of  the  external  condyle,  whilst  the  internal 
condyle  has  grown  downwards  and  inwards,  apparently  from  meeting  ivith  no 
hindrance  in  those  directions.  Considerable  indications  of  cauliflower  exuberant 
growths  of  hone  foreign  to  our  present  object  in  this  section  are  also  jiresent. 
This  flgure  was  published  by  us  in  1853* 

Fig.  14. — The  same  hones  placed  by  us  nearly  i)i  their  tiaUiral  relation,  lo 
show  the  gap  between  tite  external  condyle  and  opposite  part  of  the  tibia.  The 
artist  has  placed  the  femur  in  a  too  perpotdicular  position,  a  circumstance  which 
only  slightly  affects  tlie  fact  wliicli  the  flgure  illustrates. 


■■'•  Little  :  on  '  Defoiiuities  of  the  Humaii  Frame,'  p.  211  et  seq. 


VIEWS    01''    SANDIFORT    AND    MAYER. 


45 


Fm.  15. 


We  are  indebted  to  A.  Mayer*  for  the  next  step  in  posi- 
tive knowledge  of  the  morbid  anatomy.  He  describes  a 
non-rachitic,  but  atonic,  case  of  genu-valgum,  in  which  the 
patient,  a  boy,  walked  well  up  to  the  age  of  nine  years, 
when  he  had  severe  pertussis  of  seven  months'  duration, 
became  wasted,  and  had  so  great  relaxation  (erschlaffung) 
of  the  ligaments  of  the  knees  that  from  this  period  the 
knees  began  to  incline  inwards  (oj;.  cit., 
p.  16).  During  four  years  he  hobbled 
about,  until  marked  knock-knee,  the  re- 
sult of  statical  influence,  was  discovered. 
At  the  age  of  fourteen  the  lameness  was 
no  longer  dependent  on  local  weakness. 
The  thigh  and  leg  bones  began  to  parti- 
cipate in  the  disorder,  inasmuch  as  the 
external  condylar  parts  of  them,  owing 
to  friction  and  absorption,  became  flat- 
tened, whilst  the  internal  condyles  of 
both  femora  became  enlarged  and  pro- 
minent. From  the  age  of  sixteen  the 
knees  began  to  cross  over  one  another 
(see  fig.  15),  and  the  feet  to  assume 
the  form  of  flat-foot.  At  the  age  of  eighteen  Mayer  removed 
a  wedge  of  bone  from  both  tibise.  Notwithstanding  certain 
difficulties,  he  had  the  satisfaction  of  seeing  his  patient's 
lameness  removed.  Unhappily  the  patient  died  from  tetanus 
two  months  after  operation  of  the  second  foot,  apparently 
through  sitting  on  wet  grass.  Mayer,  who  was  the  first  to 
employ  osteotomy  for  the  cure  of  knock-knee,  was  able  from 
a  previous  twenty-five  years'  clinical  study  of  this  distortion, 
in  his  private  Orthopaedic  Hospital  in  Wurzburg,  to  start  on 
his  career  of  osteotomy  with  a  large  stock  of  knowledge  of 
the  difierent  forms  of  the  deformity.  As  with  pioneers  in 
most  new  surgical  operations,  his  successes  were  chequered 

'■'•  Op.  cit. 


Extreme  atonic  in-knee, 
from  Mayer. 


46 


IN-KNEK    DISTORTION. 


with  disasters.  Deaths,  after  several  of  his  operations,  fur- 
nished him  at  least  with  the  opportunity  of  studying  the 
mechanical  conditions  of  knock-knee.  Some  of  Mikulicz's  * 
anatomical  observations  were  derived  from  a  similar  source. 
A.  Mayer,  though  apparently  unacquainted  with  our  earlier 
writings,  has  confirmed  our  teaching  as  to  the  influence 
of  arrested  growth  of  the  external  condyle  of  the  femur,  and 

Fig.  16. 


Fig.  17. 


found  the  external  articular  opposing  surface  of  the  tibia 
similarly  affected,  whilst  the  internal  condyle  had  gradually 
enlarged. 

The  two  figures  above,  from  Mayer,  represent  (fig.  16) 
the  right  non-rachitic  genu- valgum,  from  which  a  wedge  of 

"-■=  '  Die  seitliclieu  Verki'iiiumungen  aui  Knie,'  voii  Dr.  Joliaun 
Mikulicz.  *  Arcliiv  fur  Klin.  Cliirargie,'  von  LaiigeuLeck,  Berlin,  1879, 
p.  561. 


MORBID    ANATOMY.  47 

bone  has  been  removed  below  the  knee  previous  to  placing 
the  leg  in  a  straight  line ;  and  (fig.  17)  the  bones  of  the 
similarly  affected  left  knee,  which  had  been  successfully 
treated  by  osteotomy,  and  removal  of  a  wedge  of  bone  below 
the  knee  four  months  before.  Post-mortem  examination  of 
the  bones  of  the  knees,  Mayer  states  (p.  22),  "confirmed 
the  presence  of  considerable  enlargement  of  both  internal 
condyles,  and  considerable  flattening  of  both  external  con- 
dyles, with  relaxation  of  all  knee  ligaments."  It  shows, \ 
however,  another  anatomical  fact,  important  as  regards 
treatment,  viz.,  the  great  obliquity  of  the  line  of  the  articular 
surfaces  of  the  femur  and  tibia,  from  the  outer  side  of  the 
joint,  downwards  and  inwards.  The  obliquity  of  this  line 
appears  greater  in  the  left  limb  than  in  the  right,  probably 
from  the  left  having  been  more  affected.  In  the  remarks 
which  follow  on  treatment  we  shall  derive,  we  consider,  a 
cogent  argument  in  favour  of  osteomizing  the  femur  instead 
of  the  tibia,  and  in  favour  of  the  supra-condylar  operation. 
We  consider  the  continuance  of  so  oblique  a  state  of  things 
very  apt  to  induce  relapse  of  distortion. 

Mikulicz's  study  of  the  morbid  anatomy  of  in-  and  out- 
knee  led  to  important  contributions  to  the  knowledge  which 
has  recently  been  acquired.  In  his  published  table  of  cases 
he  has  included  some  distinctly  rachitic  with  others  which 
have  occurred  during  adolescence  from  debility,  phthisis, 
and  probably  over-growth.  The  grosser  anatomical  changes 
of  the  knee  joint,  though  varying  in  origin  and  degree,  were 
similar  in  all  cases,  a  fact  which  shows  how  great  was  the 
share  of  influence  in  the  resulting  deformity  exercised  by 
circumstances  independent  of  the  knee  joint  or  of  the  normal 
condition  of  the  internal  condyle.  We  have  already  to  some- 
extent  shown  that,  whichever  of  the  primary  causes  of  in- 
ward yielding  of  the  knee  has  been  in  operation,  the  resulting 
grosser  changes  of  form  and  relation  are  the  same.  It  is 
evident,  therefore,  that  it  cannot  be  correctly  stated  that 


48  IN-KNEK    DISTORTION. 

geiiu-valgum  essentially  owes  its  origin  to  abnormal  growth 
of  the  internal  condyle.  In  fact,  those  who  attribute  in- 
ward yielding  of  the  knee  to  primary  enlargement  of  the 
internal  condyle  have  mistaken  the  consequence  for  the 
cause. 

From  the  history  of  several  of  the  cases  narrated  by 
Mikulicz  as  having  been  attacked  for  the  first  time  by 
rickets  during  adolescence,  we  are  of  opinion  that  they 
were  atonic  cases,  and  not  rachitic,  or,  if  rachitic,  that 
the  slightly  arrested  rickety  distortion  had  been  present 
in  earl_y  childhood,  had  been  stationary  for  some  years, 
and  had  become  suddenly  aggravated  through  statical  in- 
fluence and  undue  weight,  carrying  and  standing,  during 
the  adolescent  fast-growing  period,  and  not  from  a  second, 
or  from  a  prolonged,  attack  of  rickets. 

Mikulicz  attributes  all  changes  of  the  form  of  bones, 
from  the  influence  of  gravity,  to  rachitic  softening.  He  has 
overlooked  the  fact  that,  under  the  influence  of  gravity, 
bones,  not  rachitic,  may  undergo  changes  of  form,  as  in 
Mayer's  first  osteotomized  case,  just  referred  to.  Clinical 
experience  of  atonic  knock-knee,  club-foot,  and  scoliosis, 
daily  shows  changes  of  the  form  of  bones  where  no  sign  of 
rickets  exists.*  Cases  of  genu-valgum  from  spasm  or 
paralj^sis  of  muscles,  and  from  chronic  rheumatism,  are  in- 
stances. Compensatory  curvature,  genu-varum  with  cur- 
vature of  the  femur  and  tibia  of  one  leg,  owing  to  the 
individual  having  had  fracture,  ending  in  shortening  of  the 
other  leg  (without  a  trace  of  rickets),  is  a  case  in  point. 
So  also  is  the  occasional  case  of  a  person  having  atonic 
genu-valgum  of  one  limb,  and  what  may  be  termed  com- 
pensatory genu-valgum  of  the  other,  by  its  getting  out  of 
the  way. 

From  the  results  we  have  witnessed  of  the  gradual  irre- 

■■'  Holmes's  'System  of  Surgery,'  article,  "Eickets,"  2iul  edition, 
by  Alexander  Shaw;  and  3rd  edition,  by  Dr.  Little. 


MORBID    ANATOMY.  49 

sistible  force  of  gravity,  we  are  convinced  that  the  strongest 
bone  of  the  human  body,  continuously  exposed  to  it  in  a 
forced  unnatural  direction  for  months  and  years,  would  give 
way  under  its  influence,  and  become  curved  in  the  same 
manner  as  we  see  bones  distorted  from  disease.  ' 

This  supposition,  based  upon  facts  daily  witnessed, 
enables  the  orthopaedist  to  apply  pressure  Avith  confi- 
dence in  the  treatment  of  some  distortions,  availing  him- 
self of  the  three  powers  more  or  less  at  his  command — 
gravity,  muscular  action,  and  gentle  gradual  mechanical 
force. 

The  figures  (18,  19,  20),  from  Mikulicz,  satisfactorily 
represent  the  different  relations  of  the  bones  to  each  other. 
Fig.  19,  the  normal  relation  ;  fig.  20,  their  relation  in  inward 
yielding  of  the  knee ;  fig.  18,  their  relation  in  outioard  yield- 
ing of  the  knee. 

The  perpendicular  line  in  each  of  the  figures,  extend- 
ing from  the  summit  of  the  head  of  the  thigh  bone  to  the 
middle  of  the  ankle  joint,  shows  the  direction  in  which, 
according  to  him,  the  limb  is  laden  with  the  weight  of  the 
body.  In  the  normal  condition,  fig.  19,  this  line  {a,  c)  passes 
almost  exactly  through  and  between  the  middle  of  both 
condyles.  In  a  slight  degree,  owing  to  the  naturally  slightly 
oblique  or  adducted  position  of  the  lower  end  of  the  femur, 
there  is  a  tendency  to  inward  inclination  of  the  knee,  rather 
than  to  any  outward  inclination  of  it.  Mikulicz  says  (p.  581), 
in  reference  to  this  line,  fig.  19  (a,  c) :  "  It  is  clear  that  in 
every  normal  limb,  owing  to  the  usual  bearing  of  the  weight 
of  the  body,  an  equal  portion  of  it  is  borne  upon  both  halves 
of  the  knee  joint."  From  this  observation  it  might  be  in- 
ferred that  the  form  of  the  bones  of  the  knee  joint  and 
the  direction  of  the  line  of  gravity  in  health  do  not  favour 
the  production  of  genu-valgum.    The  brothers  Weber,*  and 

*  '  Mechanik  der  menscliliclien  Geliwerkzeuge,'  von  den  Briidern 
Willielm  und  Edward  Weber,  Gottingen,  1836. 


50 


IN-KNEE    DISTOETION. 


most  anatomists,  give  a  greater  normal  inversion  of  the 
femur  than  Mikulicz  has  done.  We  consider  that  in  health 
the  line  of  gravity  falls  slightly  to  the  inside  of  the  middle 


Fig.  18 


Fio.  20. 


Fig.  19,  a  normal  Umh ;  Fig.  20,  (jenu-valgum ;  Fig.  18,  gcnu-varum  :  (a,  c) 
line  of  gravity ;  (b,  in)  deviation;  (o)  the  diminished  external  condyle ;  («)  the 
enlarged  internal  one ;  the  'proportions  of  these  condyles  is  reversed  to  some 
extent  in  genu-varum. 

of  the  joint,  and  that  consequently  there  would  in  health  be 
a  constant  tendency  in  the  knee  to  yield  inwards,  were  this 
not  prevented  by  the  ligaments  and  muscles  of  the  joint. 


DEPOSIT    OF    NEW    BONE    WHERE    REQUIRED. 


51 


"^"^ 


^ 


Fig.  20  shows  that  when  relaxation  and  weakness  of  the 
ligaments  and  muscles  (atonic),  or  softening  of 
the  bones  (rickets),  take  place,  the  joint  yields 
inwards,  leaving  the  centre  of  gravity  far  to  the 
outside.  It  is  less  easy  to  explain  the  rarer  case, 
in  which  the  knee  yields  outwards  (genu-extror- 
sum  curv.),  fig.  18. 

To  the  above  figures  from  Mikulicz,  we  have 
added  a  fourth,  fig.  21,  which  represents  Miku- 
licz's genu-valgum  straightened.  It  exhibits  the 
"gap"  we  have  so  often  mentioned,  as  existing 
in  the  early  stage  of  genu-valgum,  which,  now 
we  have  put  the  bones  in  their  normal  relation 
to  the  perpendicular,  requires  to  be  filled  up  in 
the  growing  patient  by  Nature,  adding  bone  and 
cartilaginous  material  on  the  outer  side  of  the 
joint  when  the  limb  is  held  straight  by  mechanical 
means,  as  represented  by  the  dotted  lines  be- 
tween the  outer  condyle  and  opposite  part  of  the 
tibia.  (See  also  p.  27.)  Compare  this  diagram 
of  straightened  knee  with  that  of  Mayer  (fig.  16), 
drawn  after  Nature,  which  shows  that  in  the 
advanced  stage,  when  the  knee  is  extended,  the 
biceiDS  muscle  and  external  ligament  keep  the 
external  condyle  and  opposing  part  of  the  tibia 
closely  applied  to  each  other. 

C.  Hueter*  has  confirmed  our  opinion  ex- 
pressed in  1842,  that  the  weight  of  the  body  being  thrown! 
too  long  and  too  frequently  upon  the  articular  tissues, 
which  are  too  soft  and  too  yielding,  is  the  essential  fact  in 
the  origin  of  genu-valgum.  He  adds,  that  the  external  half 
of  the  articular  surfaces  of  femur  and  tibia  become  arrested 
in  their  growth,  owing  to  an  excess  of  weight  being  impressed 

*  Dr.  C.  Hueter :  '  Klinik  der  Gelenkkrankheiten  rait  Einscliluss 
der  Orthopgedie,'  1877,  2ter  tlieil,  p.  259. 


52  IN-KNEE    DISTORTION. 

upon  them  during  the  rotation  outwards  of  the  femur,  which 
attends  full  extension  of  the  knee.  He  goes  too  far  in  pro- 
claiming that  every  adult  has  a  minimum  degree  of  genu- 
valgum. 

This  small  amount  of  normal  inward  inclination  is 
doubted  also  by  Mikulicz.  He  says,  that  if  it  existed  the 
weight  of  the  body  would  in  every  healthy  person  induce 
an  in-knee.  And  so  it  would  happen  were  it  not  that  in 
the  normal  individual  the  powerful  ligaments  and  muscles 
surrounding  the  knee  joint  support  it  so  effectually,  and  so 
thoroughly  balance  each  other,  that  our  clinical  genu- 
valgum  is  not  produced  in  the  healthy  and  robust,  exce[)t 
from  over- work  or  from  accommodation.  See  pp.  11,  37. 
A  proof  of  the  accuracy  of  this  view  is  afforded  by  the  fact, 
already  mentioned,  of  its  origin  from  any  of  the  numerous 
causes  which  disturb  the  equilibrium  of  the  thigh  muscles, 
e.g.,  in  certain  forms  of  infantile  paralysis,  and  in  sj)astic 
contraction  of  thigh  muscles,  which  sometimes  follows 
asphyxia  neonatorum. 

C.  Hueter  holds  the  view  that  the  external  half  of  the 
opposing  articular  surfaces  of  the  knee  becomes  arrested  in 
growth,  owing  to  an  excess  of  weight  being  impressed  upon 
it  during  the  rotation  outwards  of  the  tibia,  ichicli  attends  full 
extension  of  the  knee.  The  rotation  in  question,  in  our 
opinion,  is,  if  any,  much  less  than  he  supposes.  Indeed,  as 
was  long  since  shown  by  the  brothers  Weber,*  the  arrange- 
ment of  the  lateral  and  crucial  ligaments  of  the  joint  in 
health  oppose  rotation  outwards  of  the  tibia  in  the  extended 
position  of  it.  We  have  proved  this  from  examination  of 
the  dissected  knee,  the  ligaments  of  which  had  not  been 
divided. 

So  when  we  firmly  hold  together  a  femur  and  its  tibia, 
from  an  anatomical  cabinet,  in  a  jjosition  of  full  extension, 
we  are  unable  to  give  to  the  tibia  any  outward  rotation. 

'•'  Weber,  op,  cit.,  p.  201. 


INFLUENCE    OF    TENSOR   VAGINiE    FEMORIS. 


53 


Fig.  22. 


F 


We  would  say,  on  the  contrary,  that  owing  to  the  form  of 
the  articular  surfaces  of  the  fe- 
mur and  tibia,  and  of  the  tibial 
spine,  the  more  the  knee  is  hent 
the  more  readily  can  the  leg  be 
rotated  outwards,  and,  vice  versa, 
the  more  firmly  the  joint  is  ex- 
,  tended  the  less  easily  can  the 
leg  be  rotated  outwards. 

In  the  figure  (fig.  22),  the 
patient  being  over-fatigued,  the 
knee  joint  (b)  has  slightly  yielded 
inwards,  and  the  inner  margin 
of  the  foot  tends  unduly  to  the 
ground  (talipes  valgus),  the  outer 
margin  of  the  foot  (g)  proportion- 
ately raised  from  it,  and  the  toes 
disposed  to  be  too  much  everted. 
The  line  of  gravity,  instead  of 
passing  through  the  head  of  the 
femur  (as  in  fig.  19)  and  through 
the  middle  of  the  knee  and  ankle 
joints,  passes  in  a  line  (/) 
through  the  sacro-iliac  synchon- 
drosis and  towards  the  inner  side 
of  the  heel.  The  letter  (d)  indi- 
cates the  direction  of  the  lumbar 
vertebrae,  when,  as  in  this  figure, 
the  patient  is  supposed  to  rest  on 

the  right  limb,  the  left  being  placed  in  advance.  The  line 
( j9,  x)  indicates  the  sinking  of  the  left  half  of  the  pelvis,  and 
the  raising  of  the  right  half. 

Whilst  we  are  touching  upon  the  physiological  circum- 
stances which  may  favour  or  prevent  genu-valgum,  we  may 
remark  that  the  tensor  vaginae  femoris,  with  its  tendon-like 


54  IN-KNEE    DISTORTION. 

expansion,  the  fascia  lata,  appears  also  to  exercise  a  con- 
trolling influence  upon  both  inversion  and  rotation  of  the 
knee.  (See  a,  h,  fig.  22.)  "We  are  indebted  to  Mr.  Alexander 
Shaw  for  this  diagram,  intended  to  illustrate  the  production 
of  rotatorj^-lateral  spinal  curvature.  It  shows,  however,  at 
the  same  time,  the  manner  in  which  fatigue  is  prevented 
from  engendering  knock-knee  in  the  robust.  Fatigue  may 
produce  temporary  knee  inversion  and  some  flat-foot  when 
the  individual  stands  unduly  on  one  leg ;  a  night's  rest  in  the 
healthy  person  removes  the  fatigue-weakness  of  the  pre- 
ceding day.  But  when  the  fibrous  structures  suffer  from 
atonic  influences  (dietetic  or  other)  a  night's  rest  does  not 
suffice  to  remove  the  weakness ;  on  the  contrary,  genu- 
valgum  maybe  gradually  engendered.  In  health,  and  freedom 
from  undue  fatigue,  the  tensor  vaginae  {a),  and  fascia  passing 
over  both  hip  and  knee  joints,  tend  by  their  tension  to 
stiffen  both  joints  in  the  extended  position  to  prevent  inward 
yielding  of  the  knee,  and  enable  the  individual  to  rest  on  one 
leg,  and  support  the  weight  of  the  body  with  a  minimum 
expenditure  of  muscular  power. 

Mikulicz  has  raised  an  important  question  as  to  the  part 
of  the  articular  end  of  the  femur  in  which  the  greatest 
morbid  changes  take  place.  He  attributes  the  changes  to 
unequal  growth  of  the  diaphysial  border  of  the  bone,  in 
which  opinion  he  is  followed  by  Macewen.  Mikulicz  says, 
p.  598:  ''It  is  clear  that  the  alteration  of  length  on  the 
inner  side  of  the  femur  arises  not  from  alteration  of  the 
epij)hysis,  but  is  confined  to  the  lowest  part  of  the  diaphysis." 
And  further  on  he  says:  "It  is  seen  that  in  genu-valgum 
the  unchanged  epiphysis  is  attached  to  the  altered  diaphysis 
in  an  oblique  direction,  which  is  a  very  characteristic  anomaly 
at  the  lower  end  of  the  femur." 

The  series  of  outlines  opposite,  from  Mikulicz  (fig.  23), 
which  represent  the  front  section  of  the  femur,  taken  from 
a  normal  subject  and  from  two  different  subjects  of  genu- 


CHANGES   EFFECTED    IN    THE    FEMORAL    DIAPHYSIS. 


55 


valgum,  enables  us  to  follow  the  successive  increase  of  the 
divergence  in  form  and  length  of  the  internal  and  external 
parts  of  the  lower  end  of  the  shaft  of  the  femur. 

We  consider  that  the  torsion,  described  by  Linhart  and 
Mikulicz,  at  the  lower  end  of  the  femur  and  the  smaller  bone 
changes  on  the  upper  and  internal  part  of  the  tibia  are 
statical  and  adaptive,  and  that  they  may  occur  both  in 


Fig.  23. 


A,  B,  c  are  three  representations,  from  Mikulicz,  of  the  vertical  sections  of 
the  loiver  ends  of  the  femur  in  adolescents  and  adults,  seen  from  the  front :  a  re- 
presents a  section  of  a  normal  femur ;  b,  c  represent  sections  of  fenmirs  from 
subjects  affected  ivith  genu-valgum  in  advancing  degrees  of  severity  :  the  ivavy 
lines  ending  {b,  a)  indicate  the  jtinction  of  each  epiphysis  with  the  diaphysis, 
and  show  the  increasing  obliquity  of  the  epiphysial  line  as  the  deformity  in- 
creases compared  ivith  the  sound  bone.  The  gradual  increase  of  the  diaphysial 
portion  of  the  internal  condyle,  and  to  a  slight  extent  of  the  epiphysial,  is  shoivn 
in  c. 

rickety  and  also  non-rachitic  cases.  We  do  not  doubt  that 
microscopical  examination  of  atonic  or  purely  statical  cases 
will  some  day  show  wherein  the  minute  bone  formation 
differs  from  the  norm  and  from  rickets.  We  may  also  learn 
to  what  extent  the  texture  of  the  diaphysial  and  epiphysial 
parts  of  the  bones  are  affected  during  growth,  and  possibly 


66  IN-KNEE    DISTORTION. 

afterwards,  by  the  strain  experienced  there  by  over-loading 
in  an  improper  position,  and  by  the  hyperaemia  sometimes 
kept  up  there  for  months  and  years  during  the  advanced 
stage. 

MikuHcz  states  that  the  epiphyses  are  not  essentially 
involved  (p.  600).  We  are  of  opinion  that  his  fig.  23  shows 
that  the  epiphysis  does  increase  on  the  internal  half  of  the 
articular  surface  of  the  femur  both  in  breadth  and  depth, 
though  in  a  much  smaller  degree  than  the  diaphysis. 
Mikulicz  regards  the  one-sided  enlargement  of  the  diaphysis 
of  the  femur  as  a  characteristic  of  genu-valgum. 

There  is  another  physical  condition  in  atonic  inward 
inclination  of  the  knee  daily  observed  clinically,  especially 
in  the  early  stages,  worthy  of  mention, — abnormal  hyper- 
extension  of  the  knee  joint.  This  condition  is  an  exaggera- 
tion of  the  normal  hyper-extension,  and  rarely  amounts  to 
double  the  normal  limit.  It  is  a  state  of  things  not  to  be 
overlooked  in  treatment.  We  have  observed  that  in  infantile 
unmistakable  rachitic  genu-valgum  the  knees  are  apt  to  be 
found  unduly  flexed,  and  slightly  contracted  and  stiff,  rather 
than  affected  with  hyper-extension  or  laxity.  However,  in 
the  advanced  stages  of  rickety  in-knee,  in  which  instruments 
have  been  long  unavailingly  used,  much  hyper-extension 
may  exist. 

An  important  pathological  fact  is  that  the  distortion 
disappears  when  the  joint  is  bent.  So  universally  is  this 
the  case,  that  it  may  be  regarded  as  the  pathognomonic 
sign  of  simple  genu-valgum.*  There  is  no  other  single  fact 
which  holds  an  equal  j)Osition.  Various  opinions  as  to  this 
disappearance  of  the  distortion  have  been  offered. 

We  believe  the  true  explanation  to  be  that,  however  much 
the  condyles  of  the  femur  in  knock-knee  may  differ  in  length 

■-•'  We  have  shown  (p.  10)  that  there  are  several  simple  forms  of 
in-knee  as  well  as  sub-forms,  in  which  the  in-knee  is  the  minor  part 
of  the  affection. 


EXPLANATION   OF    DISAPPEAEANCE    ON   BENDING.  57 

perpendicularly,  they  remain  of  the  same  length  antero--! 
posteriorly ;  therefore  when  the  patient  bends  the  knee  the 
posterior  surfaces  of  the  condyles  present  in  a  horizontal 
plane  towards  the  articular  facets  of  the  tibia  ;  but  when  the 
patient  assumes  the  erect  position,  or  extends  the  knee,  the 
lower  ends  of  both  condyles  impinge  upon  the  tibia.  Now, 
however,  owing  to  the  deficiency  in  depth  of  the  outer  condyle, 
the  plane  of  the  articular  surfaces  becomes  oblique,  the 
internal  part  being  depressed  and  the  external  part  elevated, 
the  tibia  is  forced  to  resume  the  position  of  abduction,  and 
genu-valgum  is  at  once  reproduced.     (See  fig.  16.) 

We  have  already  shown  that  in  the  young,  if  the  knee 
joint  be  extended  by  the  hands  of  the  surgeon  in  the  manner 
described  (pp.  27-29),  the  distortion  does  not  return,  so 
long  as  the  surgeon  holds  the  limb  straight.  In  the  section 
on  treatment  it  will  be  fully  shown  that,  whether  it  be  by 
instrumental  means  or  by  supra-condylar  osteotomy,  the 
cure  of  in-knee  can  best  be  effected  by  working  upon  the 
same  lines. 

Mikulicz  has  strongly  directed  attention  to  the  frequently 
slender  conformation  of  the  shaft  of  the  bones  in  genu- 
valgum,  as  he  says,  erroneously  we  believe,  from  rachitis, 
amounting  frequently  to  a  reduction  of  one-fourth  of  their 
diameter.  A  still  greater  reduction  of  diameter  may  be  pro- 
nounced to  exist  from  clinical  examination  in  paralytic  cases, 
which,  as  elsewhere  stated,  often  exhibit  considerable  genu- 
valgum.  We  do  not  know  of  any  post-mortem  examination 
of  a  recognised  long-paralysed  limb  from  infancy  affected 
with  knock-knee. 

Possibly  rachitic  bones  are  sometimes  slender ;  but  our 
experience,  derived  from  clinical  observation  and  anato- 
mical sources,  is  that  rachitic  bones  have  not  only  increased 
hardness  (eburnation),  but  often  increased  bulk.  Bearing 
in  mind  that  the  bones  of  the  normal  skeleton  vary  in  bulk, ; 
and  that  rachitic  subjects. are  often  more  or  less  dwarfed, 

I 


68  IN-KNEE    DISTORTION. 

'  we  should,  -vrben  determining  the  slenderness,  or  the  con- 
traiy,  of  rachitic  bones,  compare  them  with  the  hones  of 
persons  who  have  arrived  at  a  similar  age  in  ordinary  good 
health,  hut  who  are  of  short  stature.  This  is  not  the  place 
to  enlarge  on  the  varieties  of  the  condition  and  size  of  the 
bones  under  different  circumstances  of  human  development ; 
but  we  may  remark  that  the  subjects  of  asphyxia  neonatorum 
have  remarkably  slight  and  fragile  bones,  and  often  suffer 
from  knock-knee. 

We  cannot  avoid  the  belief  that  so  able  an  investigator 
as  Mikulicz  has  been  misled  on  this  point  of  bone-wasting 
in  rickets,  through  his  not  having  been  aware  that  genu- 
valgum  may  occur  from  causes  independent  of  rickets. 
Mikulicz  has  from  this  cause  misled  so  able  a  surgeon  as 
Macewen.  Mikulicz  has,  if  we  mistake  not,  in  his  table  of 
cases,  included  those  of  atonic  non-rachitic  origin  who  had 
died  from  phthisis,  and  probably  instances  of  those  which 
appear  to  have  had  their  origin  in  infantile  paral3^sis.  Such 
errors  may  readily  arise  when  acquaintance  with  the  cases 
is  only  made  in  the  anatomical  department,  and  not  con- 
jointly with  clinical  examination  of  the  earliest  stage  in 
young  infants,  as  well  as  in  adolescents  and  adults.  Miku- 
licz acknowledges  the  existence  of  enlargement  and  flatten- 
ing of  the  articular  surface  of  the  external  condyle  as  a 
matter  of  secondary  importance,  explained  by  the  pre- 
ceding relative  or  absolute  statical  disturbance  through 
over-loading. 

Our  observation  of  the  effects  of  treatment  (Diag.,  p.  27), 
whether  it  be  by  means  of  instruments  alone,  or  with  the 
aid  of  supra-condylar  osteotomy,  shows  that  the  anatomical 
changes  of  the  external  condylar  side  of  the  joint  are  of 
primary  importance.  Associated  with  these  changes  Miku- 
licz found  the  articular  cartilage  of  the  external  condyle  and 
the  corresponding  articular  cartilage  of  the  tibia  more  or 
less  thickened,  sometimes  to  the  extent  of  6  or  7  milli- 


ATROPHY  AND  HYPERTROPHY  OP  STRUCTURES.      59 

metres,  whilst  over  the  internal  condyle  the  cartilage  was 
found  to  be  particularly  thin  and  altered  in  its  microscropical 
appearance,  so  that  he  lays  down  the  thesis  that  the  car- 
tilages of  the  knee  joint  on  the  external  over-loaded  half  of 
the  articular  surfaces  are  in  a  state  of  hypertrophy,  whilst, 
on  the  contrary,  the  internal  unloaded  half  of  the  cartilages 
is  in  a  state  of  atrophy.  This  abnormal  change  of  cartilage 
is  in  accordance  with  the  knowledge  obtained  from  other 
sources,*  that  cartilage  wastes  where  it  ceases  to  be  in 
normal  contact  with  another  cartilage,  so  that  it  ceases  to 
be  exposed  to  normal  pressure.  ' 

Mikulicz  states  that  he  sometimes  observed  traces  of 
arthritis  deformans  in  the  outer  half  of  the  articular  sur- 
faces, disappearance  of  the  previously  thickened  cartilage, 
erosion  of  the  bones,  and  cauliflower  osteophytic  formations, 
such  as  are  represented  elsewhere.  (See  fig.  13,  p.  44,  from 
Sandifort.)  It  is  evident  from  these  remarks  by  Mikulicz, 
on  signs  of  rheumatism  found  by  him  in  anatomical  in- 
spections of  genu-valgum,  that  he  was  not  aware  that 
rheumatism  is  frequently  a  primary  source  of  knee  weak- 
ness and  genu-valgum,  just  as  atonic,  rickety,  paralytic 
and  other  disorders  may  be  primary  causes  of  the  same 
distortion  (p.  8). 

Mikulicz  found  that  the  external  facet  of  the  patella 
had  shared  the  fate  of  the  external  condyle,  as  well  as  the 
external  articular  surface  of  the  tibia.  The  external 
articular  surface  of  the  patella  and  the  corresponding 
articular  surface  of  the  external  condyle  "were  much 
changed  from  exposure  to  the  enormous  pressure  exercised 
by  the  quadriceps  femoris." 

In  regard  to  the  condition  of  the  ligaments  in  genu- 
valgum  he  found  no  striking  changes ;  the  external  lateral 
was  sometimes  shortened,  and  the  internal  lateral  was  some- 

*  C.  Eeylier  :  '  Ueber  die  Veriiucleniugeu  der  Geleuke  bei  dauerude 
Ruble,  Deutsclie  Zeitschrift  fiir  Cliirurgie,'  iii.  159,  circa  1878. 


60  .  IN-KNEE    DISTORTION. 

times  thickened  and  unusually  tense,  but  not  elongated. 
He  remarks:  "This  could  not  be  otherwise,  for  in  knock- 
knee,  as  a  rule,  when  the  knee  is  extended,  it  does  not  hang 
loosel}^  or  wobble  about."  Mikulicz  cannot  have  studied 
the  distortion  in  infants  and  very  young  children,  for  the 
"wobbling"  of  the  joint  within  the  range  of  a  straight 
limb  to  a  knock-knee  is  a  constant  remarkable  feature 
in  the  early  stages  of  the  atonic  form  (see  p.  '27)  in  young 
children. 

He  and  Yolkmann*  confirm  our  statements  t  as  regards 
the  muscles  and  tendons,  that  their  contraction  is  of 
secondary  importance,  and  is  caused  by  the  approximation 
of  their  points  of  insertion ;  the  main  resisting  muscle 
being  the  biceps.  Guerin  veg^irds  " retraction  musculaire''' 
as  the  primary  cause. 

We  have  met  with  a  few  cases  of  complete  luxation  of 
the  patella  behind  the  external  condyle ;  partial  luxation  is 
more  common.  For  its  effect  in  increasing  the  difficulty  of 
cure  by  instrumental  treatment,  see  section  on  treatment 
of  genu-valgum.  Commonly  the  semiluxation  of  the  patella 
is  of  gradual  origin,  the  wasting  of  the  external  condyle 
gradually  permitting  the  external  portion  of  the  quadriceps 
to  draw  the  patella  to  the  outside.  The  semiluxation  in- 
creases with  advancing  age,  and  increase  of  the  distortion. 
Occasionally  the  partial  luxation,  like  the  partial  genu- 
valgum  itself,  is  suddenly  converted  into  a  full  one,  through 
a  fall,  or  a  violent  effort  made  to  prevent  falling.  It  should 
be  remarked  that  when  even  one  limb  only  is  affected  with 
genu-valgum  falls  are  very  common,  probably  because  one 
sound  limb  enables  a  boy  to  be  venturesome.  We  do  not 
remember  ever  seeing  luxation  of  patella  in  a  female. 

Mikulicz  (p.  624),  after  reviewing  the  post-mortem 
appearances,  turns  to  the  constitutional  condition  of  the 

'■-  Op.  cit. 
]    Lectures  iu  '  Lancet,'  lHi2-'6.     'Treatise  on  Del'ornuties,'  185i3. 


LUXATION    OF    PATELLA.  &1 

individual,  as  one  of  powerful  etiological  influence  in  pro- 
ducing genu-valgum.     He  notes  the  fact,  well  known  to 
orthopaedic  practitioners,  that  sometimes  when  adolescents 
affected  with  genu-valgum,  or  with  flat-foot,  stand  upright, 
with  the  hands  hanging  free  by  the  side,  both  hands  and  feet 
assume  a  cyanotic  hue,  which  may  extend  some  distance  up 
the  arms  and  legs.     This  symptom  points,  in  our  opinion, 
to  some  abnormal  state  of  the  general  vascular   system 
(weak  heart  and  weak  blood-vessels),  which  is  connected  with 
the  deficient  energy  of  the  organic  muscular  system.     He 
refrains  from  venturing  upon  a  distinct  hypothesis  on  the 
subject.  He  connects  the  cyanotic  extremities  with  rachitis.* 
Our  belief  is  that  we  have  only,  or  more  often,  observed  it 
in  non-rachitic  cases, — chiefly  in    adolescents,   boys   and 
girls  of  low  tone,  of  so-called  heavy  lymphatic  temperament, 
with  feebly  acting  heart,  and  undue  liability  to  chilblains,  j 
His  remark  reminds  us  that  in  the  feebly  developed  children, ; 
born  with  cyanosis  from  congenitally  imperfect  hearts,  we  ■ 
have  sometimes  observed  genu-valgum  from  the  attendant  i 
voluntary  muscular  and  ligamentous  weakness. 

It  has  been  already  stated  that  the  grosser  features  of 
genu-valgoid  distortion  accompanying  protracted  knee 
disease  from  injury  or  inflammation,  regarded  in  their 
mechanical  aspect,  are  similar  to  those  of  ordinary  genu- 
valgum.  In  the  annexed  figure  (fig.  24)  it  is  obvious  that, 
when  during  the  stage  of  effusion  the  fibrous  structures  of 
the  knee  were  weakened  and  elongated,  the  joint  was  at  the 
mercy  of  the  femoral  muscles,  especially  of  the  biceps,  and 
that  a  series  of  mechanical  changes,  resembling  those 
occurring  in  ordinary  genu-valgum,  were  brought  about. 
Commonly,  however,  knee  disease  distortion  differs  from 

*  The  reader  needs  to  bear  in  mind  that  MikuHcz  has  written 
throughout  under  the  impression  that  only  one  form  of  in-knee 
exists,  and  has,  therefore,  mixed  together  as  belonging  to  one  single 
form  of  distortion  the  phenomena  observable  in  the  different  forms. 


62 


IN-KNEE    DISTORTION. 


ordinary  genu-valgum  by  flexion  preponderating  over 
inversion  and  abduction.  In  this  instance  the  flexion  was 
of  small  amount.  Until  we  drew  attention  to  this  subject 
surgeons  were  not  accustomed  to  approach  the  study  of 

Fig.  24. 


Genu-valgoid  distortion  from  destructive  knee  disease  with  incomplete  anky- 
losis, knee  inversion  and  lefi  abduction,  with  outward  rotation  of  tibia  and  fibula ; 
vieioed  from  the  antero-external  aspect:  {e  c,  e  c)  external  surface  of  the  con- 
dyles of  the  thiylt  bone,  presenting  naturally ;  (/)  the  proper  anterior  surface 
of  the  fibula,  and  [t)  proper  anterior  surface  of  tibia,  presenting  outwardly ; 
ip)  the  patella,  situated  diagonally  bettveen  the  front  of  the  external  condyle 
and  the  epiphysis  tibia;;  (a)  fibrous  bands  of  adhesion  betxveen  patella  and 
condyles  and  tibia. — From  preparation  F.  c.  33  in  London  Hospital  Mtiseum. 
Beproduced  from  'Little  on  Ankylosis,'  1843. 


FROM    DISEASE. 


68 


knee  disease  from  the  point  of  view  of  future  probable 
deformity  (p.  36). 

Nearly  the  same  state  of  things  is  shown  in  fig.  25, 
from  a  case  of  complete  ankylosis  of  the  knee,  from  an 
anatomical  preparation  in  the  London  Hospital  Museum. 
Reprinted  from  '  Dr.  Little  on  Ankylosis,'  1843. 

Fig.  25.  Fin.  2G. 


Genu-valgum  from 
struvwus  disease;  seen 
from  in  front. 


The  same  process  of  distortion  is  seen  in  fig.  26,  drawn 
from  the  living.  There  is  valgoid  deformity  of  the  knee, 
with  some  contraction  in  the  direction  of  flexion  from 
strumous  synovitis.  The  abduction  of  the  tibia  amounts  to 
about  30°.     Reprinted  from  'Little  on  Ankylosis,'  1843. 

The  history  of  chronic  rheumatic  in-knee  would  be  incom- 
plete without  some  further  reference  to  the  final  results 
which  occur  when  the  progress  of  the  deformity  has  not 


64 


IN-KNEE    DISTOETION. 


been  arrested  bj'  treatment.     This  is  well  shown  in  the  an- 
nexed figure  (tig.  27),  where  abduction,  liexion  and  rotation 

h'lc.  27. 


(ii)  The  upper  crlrcmHi/  of  tibia,  ichidi,  imtecuUif  presenting  two  concavitiex 
for  the  reception  of  the  condyles,  is  rounded,  like  the  head  of  the  hunwrus,  irre- 
gular on  the  surface,  in  part  divested  of  normal  cartilage,  and  elsewhere  of 
nnimtal  hardness  {ebitr nation),  and  corresponds  in  size  with  (c),  a  large  excava- 
tion formed  at  the  expense  of  the  external  condyle.     The  external  condyle  lias 


CONNEXION   WITH    DISORDER    OF    NEKVE    CENTIIIOS.  65 

entirely  disa])pcared,  from  the  combined  operation  of  prennurc,  friction,  and 
absorption;  {b)  the  internal  condyle,  not  articulatiny  toith  any  part  of  the 
tibia ;  {d  d)  the  fibula,  on  ivhich  two  enlargements  or  nodes  are  visible ;  (e  e  e  e) 
pedunculated  fibro-cartilaginous  groivths  ivithin  the  articulation;  (/)  the  patella, 
srispended  by  the  thickened  and  indurated  capsular  ligament,  and  by  the  liga- 
mentum  patellce.  The  patella  is  irregular  on  the  surface,  and  the  investing 
cartilage  has  lost  the  natural  opalescent  appearance,  alterations  evidently  due 
to  the  bone  having  ceased  to  perform  the  function  of  gliding  over  the  space 
between  the  condyles.  The  letters  {g  g)  indicate  firm^  membranous  adhesions; 
(h)  upper  part  of  the  shaft  of  tibia.  It  will  be  remarked  that  the  proper 
anterior  surfaces  of  the  tibia  and  fibula  present  externally,  these  bones  having 
undergone  outivard  rotation  on  their  perpendicular  and  transverse  axes,  the 
perinanently  contracted  condition  of  the  biceps  muscle  having  maintained  the 
displacement.  The  subject  from  which  the  draioing  is  taken  is  an  elderly 
female,  who  had  been  thus  deformed  many  years :  both  knees  ioere  similarly 
affected. — The  preparations  are  preserved  in  the  London  Hospital  Museum. 
From  ^Little  on  Ankylosis,^  1843. 

outwards  of  the  leg  have  reached  their  maximum,  the  ex- 
ternal condyle  having  been  almost  entirely  destroyed. 

Enough  has  been  said  to  prove  that  in  the  several  forms 
and  subforms  of  genu-valgum,  resulting  from  different 
diseased  actions,  the  point  on  which  the  progress  of  dis- 
tortion may  be  said  mainly  to  turn  is  undue  contact  of  the 
external  condyle  with  the  opposing  part  of  the  tibia,  and 
consequent  arrested  development  or  deterioration  of  these 
parts.  The  identity  of  distortion  and  mechanical  changes 
is  undoubtedly  due  to  the  identity  of  mechanically  acting 
forces.  The  reader  may  be  reminded  that  the  influence  of 
gravity  has  come  into  operation,  because  in  long-standing 
chronic  disease  of  the  knee,  although  the  patient  is  confined 
and  much  debarred  from  exercise,  he  is,  during  the  intervals 
of  amelioration  accompanying  chronic  disease,  tempted  to 
make  some  imperfect  use  of  the  limb. 

There  remains  a  consideration  in  the  pathology  of  atonic 
in-knee  to  which  we  have  not  alluded,  viz.,  the  influence  of 
the  cerebro-spinal  system  in  its  production.  We  have  traced 
in-knee  to  insufficient  nutrition  of  the  fibrous  tissues  (p.  14), 
as  from  the  want  of  breast-milk,  or  improper  diet,  and  too 

K 


66  IN-KNEE    DISTORTION. 

Nvatei-}'  a  diet.  We  should  be  led  too  far  into  the  domain  of 
general  pathology  if  we  entered  full}'  upon  the  enquiry 
whether  the  insufficient  and  morbid  nutrition  of  fibrous 
structures  and  muscles  were  solely  owing  to  the  defi- 
cienc}^  of  the  blood  in  plastic  materials,  or  whether  the 
•  weakened  tissues  were  influenced  indirectly  through  the 
nervous  centres.  A  not  uncommon  co-existing  symptom  in 
children  affected  with  atonic  in-knee,  at  an  age  when  the 
sphincters  are  usually  in  good  condition,  is  inability  to 
dul}^  hold  the  urine  by  day  or  night.  This  symptom  points 
to  origin  in  disorder  of  the  nervous  centre ;  but  we  may 
content  ourselves  with  expressing  the  opinion  that  the 
insufficient  nutrition  acts  simultaneously  upon  the  fibrous 
tissues  and  the  nerve  elements  of  the  central  organs  of  the 
nervous  system ;  whilst  the  fibrous  tissues  during  their 
development  suffer  directly  from  want  of  pabulum,  any 
simultaneous,  insufficient,  imperfect  building  up,  develop- 
ment and  enfeebling  of  the  nerve  centres,  cannot  fail  to 
react  injuriously  upon  the  organic  strength  of  the  peripheral 
structures  in  general. 

Some  of  the  conclusions  arrived  at  in  this  section  are 
that  the  varieties  of  in-knee  are  clearly  separable  and  dis- 
tinguishable from  one  another;  that  enlargement  of  the 
internal  condyle  is  not  pathognomonic  of  any  form  of 
in-knee ;  that  the  essentially  most  constantly  damaged 
]Darts  of  the  joint  are  the  external  condylar  part  and  the 
external  articular  portion  of  the  tibia ;  and  further,  that  in 
all  the  forms  of  in-knee  the  conditions  present  at  any  stage 
vary  in  accordance  with,  and  are  dependent  upon,  (1)  the 
nature  of  the  primary  causes  of  the  distortion,  and  (2)  the 
degree  of  influence  of  gravity  to  which  the  joint  has  been 
exposed. 

By  hand-fed  infants  (p.  9)  are  meant  such  as  have  been 
mainly  fed  upon  cow's  milk,  diluted  by  the  nurse  to  the 
extent  of  from  one  to  two  parts  out  of  four  with  water, — 


INFLUENCE    OF    DEPRIVATION    OF    BREAST    MILK.  67 

and  which,  even  m  the  present  day,  in  some  districts,  not- 
withstanding legislation  against  adulteration,  has  already 
been  diluted,— or  such  infants  as  have  been  reared  upon 
Swiss  or  condensed  milks,  or  various  advertised  artificial 
infant  foods,  to  which  cane  or  other  saccharine  matter,  and 
other  ingredients,  have  been  added  in  large  proportion. 
These  usurp  the  place  of  proper  and  more  nutritious  ingre- 
dients derived  from  milk.  Other  hand-fed  infants  are  often 
subjected  to  the  ingestion  of  smaller  or  larger  quantities  of 
various  farinaceous  substances  at  an  early  age,  when  the 
digestive  organs  are  fitted  only  to  deal  with  the  duly  liquified 
animal  flesh  substance  which  we  term  milk.  Those  infants, 
also,  who  have  been  partially  nursed  upon  breast-milk,  and 
are  therefore  more  favourably  circumstanced  than  wholly 
hand-fed  infants,  do  nevertheless  suffer  from  delayed  in- 
dependent walking,  and  often  present  in-knee.  In  short,  a 
too  watery  diet,  and  one  composed  of  substances  indigestible 
and  unassimilable  at  the  age  when  administered,  whether  it 
be  compounded  of  beef-tea,  animal  and  vegetable  solids, 
farinacea  and  frumentacea,  are  all  capable  of  engendering 
the  infantile  debility,  apt  to  terminate  in  knock-knee,  and 
other  forms  of  weakness  and  distortion.*  We  very  rarely 
witness  a  trace  of  these  distortions  in  children  nursed 
entirely  for  one  year  upon  breast-milk,  yielded  in  sufficient 

*  We  know  that  artificial  and  preserved  foods  for  infants  may  not 
only  prevent  deatli.  from  starvation,  but  that  they  also  diily  increase 
the  length  and  weight.  Despite  the  labours  of  chemists  and  manu- 
facturers they  are  inferior,  however,  to  pure  fresh  milk  of  animals, 
for  distortions  from  badly-knit  joints  most  often  occur  in  infants  and 
adolescents  brought  up  upon  them.  The  supply  of  fresh  milk  for  the 
infant  population  is  increasingly  difficult.  Might  not  something  be 
done  by  the  healthy  adults  who  are  able  to  provide  themselves  with 
other  forms  of  animal  food  besides  milk,  so  as  to  leave  a  larger  share 
of  it  to  those  to  whom  it  is  indispensable  ?  Dr.  Thomas,  of  New  York, 
has  shown  the  innocuousness,  or  rather  the  nutritive  agency,  of  neiv 
milk  injected  into  the  human  veins,  and  the  poisonous  property  of 
comparatively  stale  milk.  His  experience  confirms  the  wisdom  of 
those  nurses  who  scald  milk  as  soon  as  it  comes  into  their  possession. 


68  IN-KNEE    DISTORTION. 

quantity  by  a  healthy  mother  or  nurse,  or  ^Yho  have  been 
gradually  introduced  to  independent  feeding,  not  before  the 
sixth  or  eighth  month  of  life.  Over-fed  infants,  the  excess 
consisting  of  unsuitable  food,  may  lead,  by  the  food  being 
imperfectly  digestible  and  unassimilable,  to  the  same  result 
as  watery  insufficiency  of  food,  viz.,  alimentary  disorders, 
aufemia,  bronchitis,  and  debility.  Even  young  children 
who,  despite  of  artificial  feeding  by  cow's  milk  in  excess, 
have  apparently  passed  unscathed  through  the  perilous 
first  year  of  existence,  and  have  fattened  upon  it,  sometimes 
to  the  presenting  an  unusual  and  unnatural  obesity,  some- 
times break  down  with  in-knees  during  their  second  or 
third  year,  after  having  walked  for  three  or  four  months 
without  signs  of  weakness.  Here  the  direct  cause  of  the 
distortion  is  excess  of  weight,  compared  with  the  normal 
strength  of  the  fibrous  structures  at  the  age  in  question.  The 
proof  of  the  sufficiency  of  the  cause  has  been  furnished  by 
the  prompt  recovery  from  distortion  which  resulted  from 
reduction  of  weight  by  "  dieting,"  with  comparatively  little 
aid  from  other  measures,  and  the  occurrence  of  the  same 
series  of  facts  in  adolescent  giants. 

A  potent  aggravating  cause  of  a  large  proportion  of  the 
cases  of  infantile  genu-valgum  in  large  cities  is  to  be  found 
in  the  relative  impurity  of  the  air,  which  prevents  the 
young  child's  assimilating  organs  educing  from  the  nutri- 
ment, whatever  the  nature  of  the  food  may  be,  the  healthy 
blood  and  stamina,  which  are  more  commonly  the  lot  of 
even  the  reputed  less  well-to-do  agricultural  resident. 

Meanwhile,  through  the  greater  stimulus  to  the  brain 
of  the  two-year  old  child  in  cities,  owing  to  the  greater 
number  and  variety  of  objects  presented  to  it,  the  disposi- 
tion to  incessant  locomotion  of  the  child  in  and  out  of  doors 
is  as  great  in  towns,  if  not  even  greater.  We  believe  that 
the  space  of  two  or  three  hours  passed  on  the  common,  in 
the  country  lane,  in  the  wood,  from  the  more  soothing  and 


INHERITED    INFLUENCES.  69 

satisfying  influences  of  the  child's  surroundings, — gathering 
flowers,  sitting  down  making  daisy  chains  or  mud  heaps, — 
the  young  child's  mind  and  body  are  less  incessantly  in 
activity  than  those  of  the  town  child.  Hence  the  relative 
amount  of  locomotive  work  done  by  the  town  child  with  his 
feebler  tissues,  regarded  as  a  factor  in  the  production  of 
genu-valgum,  is  greater  than  in  the  country  child,  with  his 
less  exciting  life,  his  heartier  digestion  and  assimilation, 
and  consequent  robuster  tissues.  A  relatively  too  great  loco-; 
motive  activity  in  town  children  should,  then,  be  reckoned  as 
one  of  the  determining  causes  of  in-knee  and  allied  distor- 
tions, after  the  first  and  second  years  of  life. 

It  appears  probable,  also,  that  children  of  those  classes 
of  society  whose  life  is  passed,  either  from  choice  or  neces- 
sity, in  a  continual  round  of  excessive  cerebro- spinal  and 
intellectual  activity,  derive,  either  from  inherited  influences 
or  from  the  influence  of  their  surroundings,  a  precocity  of 
intelligence  and  a  neurosis  of  restlessness,  caused  by  the 
central  organs  of  the  nervous  system  receiving  more  than 
their  full  share  of  blood  materials.  Consequent  upon  this 
precocious  stimulation  of  the  nervous  system  there  may 
ensue  or  arise  a  proportionate  impoverishment,  arrested 
development,  loss  of  tone  and  stamina  in  the  active  and 
passive  locomotive  organs. 

There  is  reason  to  believe  that  the  proportion  of  atonic 
disorders  in  general  has  increased  with  increase  of  luxury 
and  population.  As  regards  the  probable  increase  of  weak 
or  in-knees,  it  is  probable  that  formerly  the  young  child 
when  first  "running  alone"  was  restrained  by  leading 
strings  or  the  go-cart,  and  was  less  constantly  attended  by 
helps  and  nurses,  who  continually  lead  the  child  to  fresh 
objects  of  interest  and  excitement.  Yet  the  expression  of 
"  weak-kneed "  has  been  long  enough  used  metaphorically 
to  signify  a  peculiar  indication  of  general  weakness  and 
unfitness  of  character,  and  suggests  that  our  atonic  physical 


70  IN-KNEE    DISTORTION. 

iu-knee,  with  its  attendant  liability  in  the  individual  to  fall 
about,  maj'  have  been  long  popularly  known  as  a  hindrance 
to  reaching  the  goal.  The  metaphorical  use  of  the  expres- 
sion "weak-kneed"  may  also  have  been  suggested  by  the 
bent,  tottering  knees  of  the  aged.* 

An  indirect,  if  not  also  a  direct,  hereditary  influence  in 
the  production  of  non- congenital  in-knee  may  sometimes  be 
recognised.  We  have  often  been  told  by  parents  that  one 
or  more  of  the  relatives,  or  the  husband  or  the  wife,  have 
been  similarly  affected.  Often  it  is  found  when  the  first- 
born child,  aged  four  or  five,  is  brought  for  advice,  that  two 
or  three  younger  brothers  and  sisters  have  the  same  com- 
plaint in  a  lesser  degree. 

When  weak  in-ankle  and  weak  iu-knee  co-exist  in  the 
same  individual  (p.  15)  observers  have  differed  as  to  which 
of  these  distortions  preceded  the  other.  From  analogy  with 
other  forms  of  disorder,  and  from  the  statements  of  patients 
and  nurses,  we  are  of  opinion  that  the  ankle  first  suffers,  or 
that  they  simultaneously  originate.  The  feet  being  more 
exposed  to  view,  the  weak  ankle  is  more  likely  to  attract 
notice. 

In  atonic  in-knee,  t  as  before  observed,  and  as  shown  in 

*  Dr.  Johnson  employs  the  terms  "in-kneed"  and  "knock-kneed" 
to  express  genu-valgum  and  genu- varum.  We  have  (p.  1)  given  our 
reason  for  prefen-ing  "in-knee"  to  "knock-knee,"  and  see  less  reason 
for  using  Latin  terms  when  we  possess  longer  used  and  more  expres- 
sive English  ones. 

I  We  prefer  the  term  atonic  to  that  which  has  been  given  to  it  by 
Volkmann,  viz.,  idiopathic,  because  it  deiiues  the  nature  of  the  case, 
and  because  atonic  in-knee,  as  we  believe  we  shall  have  proved, 
springs  from  a  more  or  less  general  atonic  condition  of  the  system,  as 
shown  by  the  frequent  co-existence  of  atonic  flat-foot,  atonic  scoliosis, 
and  even  other  atonic  affections  (p.  15)  with  it.  Atonic  in-knee  is  no 
more  idiopathic,  peculiar,  or  standing  alone  or  by  itself,  than  rickety 
in-knee  is  idiopathic.  On  the  contrarj^  both  atonic  and  rachitic  in- 
knee  are  instances  of  what  some  pathologists  have  described  as 
deuteropathic  affections,  i.  e.,  products  of  another  disorder,  atonic  in- 
knee  of  an  atonic  condition  of  system,  and  rachitic  in-knee  of  a  rickety 
state  of  system  (rachitis). 


ABSENCE    OF    RICKETY    SIGNS. 


71 


Fig.  28. 


figs.  15,  28,  no  positive  signs  of  rickets  can  be  discovered, 
unless  we  were  prepared  to  regard  the  weakness  in  question 
as  the  first  stage  of  that  disease  (see  p.  41).  Dentition  may 
be  behindhand.  At  twelve  or 
fourteen  months  old  the  child 
may  have  cut  only  two  or  four 
teeth,  but  these  are  apparently 
of  good  texture,  as  will  also  be 
the  second  set  of  teeth  if  no 
rickets,  syphilis,  or  mercurial 
poisoning  have  been  present. 
The  child  may  show  active  desire 
to  use  the  limbs,  but  may  not 
have  sufficient  strength  to  raise 
himself  unaided  to  his  feet.  If 
able  to  effect  spontaneous  loco- 
motion, he  often  does  it  with  the 
aid  of  articles  of  furniture.  Weak- 
ness in  the  loins  may  be  sus- 
pected, but  distinct  too  great 
hoUowness  of  this  part  (anterior 
lumbar  curvature  of  spine,  lor- 
dosis) is  absent.  The  abdomen 
may  be  rather  large,  as  it  com- 
monly is  in  all  children  of  the 
age,  but  the  disproportionate 
tumidity  of  distinct  rickets  is 
absent.  There  is  no  discoverable 
enlargement  at  the  place  of 
junction  of  the  ribs  with  their 
cartilages,  no  enlargement  of  the  joints  of  the  extremities, 
no  flattening  of  the  ribs  and  diminution  of  chest  capacity, 
and  no  curvatures  of  the  shafts  of  the  long  bones.  The 
head  is  well  shaped,  and  the  face  well  proportioned  to  the 
cranium. 


Atonic  in-knees,  slight;  the 
'symmetry  as  regards  contour, 
stoutness,  and  length,  exchules 
the  notion  of  rickets.  Com- 
pare the  more  severe  rickety 
knees,  fig.  4,  and  their  ivant 
of  symmetry.  The  posterior 
view  of  this  case  is  sitoivn  at 
fig.  12. 


72  IN-KNEE    DISTORTION. 

It  is  well  known  that  amongst  certain  oriental  nations 
the  joints  are  so  ill-knit  that  the  finger  joints  are  unduly 
loose  compared  with  the  corresponding  joints  of  Em'opeans, 
so  that  the  fore  finger,  at  the  metacarpo-phalangeal  joint, 
can  be  extended  to  such  an  extent  that  it  can  be  placed  at 
a  right  angle  to  the  back  of  the  hand,  and  can  sometimes 
be  so  far  doubled  back  as  almost  to  touch  the  back  of  the 
hand.  We  have  observed  this  condition  of  things  in  the 
few  Hindoos  whom  we  have  met  with  in  this  country.  We 
have  seen  the  same  in  Eurasians,  and  even  in  the  case  of 
children  born  in  the  tropics  of  European  parents.  We 
have  observed  the  same  in  the  cases  of  children  born  in  this 
country  of  European  parents,  who  have  never  resided  in 
tropical  climates,  but  who  have  been  reared  with  little  or  no 
breast-milk. 

Now  the  want  of  tone  in  such  inhabitants  of  tropical  and 
semi-tropical  countries,  as  is  evinced  by  such  marked  ill- 
knit  joints  compared  to  those  of  Europeans,  is  probably 
akin  to  that  want  of  tone  met  with  by  us  in  those  children 
of  European  parents  who  have  been  brought  up  by  artificial 
feeding  instead  of  by  breast-milk,  and  which  gives  rise  here 
to  such  distortions  as  atonic  in-knee,  ordinary  non-rachitic 
twisting  of  the  spine — scoliosis,  miscalled  lateral  spinal 
curvature,  non-rachitic  atonic  in-ankle — commonly  called 
weak  ankle,  and  other  atonic  disorders.     (See  p.  14.) 

We  should  be  led  too  far  if  we  entered  fully  into  a  con- 
sideration of  the  probable  causes  of  the  state  of  things — 
atony  of  the  fibrous  structures  compared  with  Em'opeans — 
which  appears  to  be  the  normal  state  of  certain  oriental 
nations,  and  which  permits  such  laxity  of  joints  as  those  to 
which  we  have  directed  attention.  We  content  ourselves 
with  the  statement  that  climate,  diet  and  social  habits  will 
probably  on  further  investigation  be  found  to  explain  the 
condition  of  things.  It  appears  to  us  a  very  remarkable  fact 
that  less  than  a  single  generation  of  exposure  to  the  above 


ATONIC    CONDITION    IN    CERTAIN    ORIENTALS.  73 

tropical  influences  should  suffice,  as  we  have  noticed,  to 
produce  in  Europeans  the  ill-knit  condition  of  joints  almost 
peculiar  to  orientals.  We  look  for  information  on  this  sub- 
ject to  the  British  physicians  who  have  had  a  professional 
life-long  experience  in  tropical  and  semi-tropical  countries, 
especially  those  who  have  so  ably  represented  our  profession 
in  India,  the  Straits,  and  China.  We  have  had  under  our 
care  many  children  of  young  British  mothers  presenting 
the  atonic  condition  in  question,  including  in-knee  distor- 
tion,— mothers  who  had  spent  very  few  years  in  India,  but 
whose  parents  had  not  lived  in  hot  countries.  Sometimes 
the  father  and  grandfather  had  been  subjected  to  tropical 
influences ;  in  these  instances,  therefore,  it  is  presumed 
that  paternal  influence  may  have  been  more  predominant 
in  the  links  of  causation,  as  far  as  climate  was  concerned. 
In  several  children  born  in  India  of  European  parents, 
affected  with  atonic  knee  or  foot  distortion,  the  acknow- 
ledged total  or  partial  want  of  breast-milk  was  to  us  suffi- 
cient explanation.  In  others  the  mothers  were  said  to  have 
nursed  their  children,  but  often  it  appeared,  as  in  the  case 
of  many  English  born  children,  that  the  nursing  had  been 
inefficient,  or  only  partial. 

We  are  commonly  told  by  Eastern  and  African  tropical 
and  semi-tropical  travellers  that  distortions  of  all  kinds  are 
rare  among  the  natives  of  hot  countries.  We  should  like 
to  learn  the  experience  of  our  recent  great  Indian  medical 
authorities,  who  have  devoted  themselves  to  the  study  of 
the  physical  and  sanitary  welfare  of  the  natives.  Earity  of 
distortion  has  been  in  part  accounted  for  by  the  habit  of 
destroying  the  young  infant  so  affected  immediately  after 
birth.  This  circumstance  may  explain  the  absence  of  con- 
genital distortions  noticed  by  the  traveller.  If  an  habitual 
laxity  of  joints  prevail  in  hot  countries,  we  should  expect 
the  atonic  distortions,  of  which  we  are  treating  in  this  work, 
to  be  numerous.     Possibly  a  life  spent  practically  in  the 

L 


74 


IN-KNEE    DISTORTION. 


Fig.  29. 


open  air  day  and  night  for  the  greater  part  of  the  year  may 
tend  to  neutralise  the  disorder.  The  brain  and  habits  of 
the  young  amongst  the  natives  of  hot  countries  may  be  less 
energetic,  and  the  exciting  objects  fewer.  The  habit  of  dis- 
pensing with  chairs  and  tables,  and  of  passing  much  time 
on  the  ground  or  in  sleep,  may  diminish  in  hot  countries 
the  too  early  or  too  constant  use  of  the  lower  limbs,  which 
the  English  child  indulges  in,  and  reduce  the  influence  of 
statical  causes  of  distortion. 

Referring  to  the  adolescent  atonic  form,  we  stated  in 
1842  [oj).  cit.)  that  this  distortion  "is  frequently  witnessed 

in  youths  who  have  been  too 
early  employed  at  occupations 
requiring  much  standing  or  walk- 
ing, as  in  shop  and  errand  boys, 
printers,  smiths,  &c.  Constant 
standing  in  one  position  is  more 
prejudicial  than  even  undue  walk- 
ing. Occasionally  it  arises  from, 
or  rather  it  is  first  noticed  after, 
a  sprain,  a  fall,  or  other  acci- 
dental injury  of  the  knee.  Genu- 
valgum  may  exist  and  occasion 
in-knee,  and  hyper-extension  of  ^n  outward  yielding  of  the  mem- 
ber."    See  fig.  29. 

We  have  no  descriptive  evi- 
dence whether  this  case  exhibited 
other  signs  of  rickets  besides  distortion.  From  the  drawing 
(fig.  29)  we  should  consider  the  case  not  to  be  rachitic,  and 
that  the  left  limb  represents  accommodative  curvature  of 
thigh,  knee  and  leg,  in  consequence  of  the  considerable 
shortening  of  the  right  limb  produced  by  in-knee  and 
hyper-extension  of  it,  and  probably  from  pressure  of  the 
right  against  its  fellow. 

Many  cases  of  palpable  but  comparatively  slight  infantile 


rifjJit  knee,  with  outward  curva- 
ture of  left  limb.  From  Mac- 
ewen,  '  On  Osteotomy.'' 


IN    CHILDHOOD    AFTER    SERIOUS    ILLNESS.  75 

weakness  of  the  lower  extremities  are  met  with,  in  which 
the  most  experienced  physician  or  surgeon  has,  at  first  sight, 
reason  to  doubt  whether  he  has  to  do  with  (1)  sHght  in- 
fantile paralysis,  (2)  with  debility  from  insufficient  nutrition 
and  anaemia,  or  (3)  with  a  slight  amount  of  rickets.  In  such 
cases  the  weakness,  in  whichever  of  the  above-mentioned 
three  modes  it  may  have  originated,  affects  equally  all  the 
fibrous  and  muscular  structures  of  the  thighs  ;  and  the  knee 
joints,  becoming  therefore  less  firmly  braced  by  them  than 
is  natural,  yield  to  the  superincumbent  weight  of  the  head, 
upper  extremities,  and  trunk,  in  the  manner  before  described. 

We  have  seen  many  cases  which  have  occurred  at 
different  ages  between  four  and  fourteen,  in  both  sexes,  in 
children  who  were  reported  to  have  been  perfectly  sound  and 
strong  previous  to  three  or  four  weeks'  confinement  to  bed  or 
room,  with  scarlet  or  other  fevers,  followed  by  much  general 
bodily  weakness.  The  non-existence  of  distortion  before  the 
illness,  and  the  gradual  occurrence  of  it  some  weeks  or 
months  afterwards,  prove  that  the  child  had  resumed  active 
life  and  locomotion  before  strength  had  been  restored.  Bear- 
ing in  mind  the  influence  of  rapid  growth,  it  is  not  surprising 
that  a  distortion  identical  with  that  which  occurs  in  infancy 
should  be  developed  at  the  intermediate  period  mentioned. 
The  facts  suggest  the  importance  of  good  nutrition,  early 
hours,  and  avoidance  of  too  strenuous  and  too  early  applica- 
tion to  mental  and  bodily  labour  and  exercises  in  fast-growing 
adolescents,  especially  after  any  serious  illness.  It  is  rare  to 
see  curvature  of  long  bones  in  any  other  than  rachitic  cases. 

In  childhood  and  adolescence,  as  in  young  infants  de- 
prived of  breast  milk,  a  hereditary  or  acquired  predisposition 
to  this  particular  weakness,  denoted  by  want  of  robust 
appetite  and  active  digestion,  may  have  existed,  so  that 
they  have  broken  down  upon  the  application  of  exciting 
causes,  such  as  late  hours  and  undue  toil,  which  may  be 
well  borne  by  those  of  robust  constitutions. 


76  IN-KNEE    DISTOllTION. 

In  the  metropolis,  and  probably  in  all  cities,  a  large  pro- 
portion of  infants,  belonging  even  to  the  aycII  fed,  well  clothed, 
well  warmed,  yet  often  insufficiently  aired,  classes  of  societj^ 
who  are  the  subjects  of  consultation  because  of  their  inability 
to  walk  properly  alone  at  the  usual  age,  are  affected  with  de- 
bility, showing  itself  in  the  relaxed  condition  of  the  tissues 
in  general,  and  especially  of  the  fibrous  and  muscular  ones. 
But  amongst  the  well-to-do  classes  in-knee  rarely  originates 
after  childhood,  except  through  debility  induced  by  fevers. 


ON  THE  SYMPTOMS  AND  DIAGNOSIS  OF  ATONIC, 
RACHITIC,  SPASTIC,  PARALYTIC,  STRUMOUS, 
AND   RHEUMATIC   IN-KNEE. 


We  are  prepared  to  find  that  objection  will  be  made  to 
our  entire  separation  of  atonic  knock-knee  and  flat-foot  from 
rachitis,  and  it  may  be  maintained  that  reduced  tone  of 
muscles  and  of  fibrous  structures  is  a,  stage  of  rickets.  We 
have  shown  (pjp.  31-40)  sufficient  reasons  against  the  exclu- 
sively rachitic  view,  and  in  favour  of  diminished  tone,  until 
morbid  anatomy  observations  shall  have  decided  against  it. 
Occasionally,  when  a  child  having  previously  walked  is 
"taken  off  his  legs,"  or  having  reached  the  age  when  he 
should  walk  does  not  walk,  it  is  in  the  earliest  stage  difficult 
to  distinguish  between  the  incubatory  softening  stage  of 
rickets  about  to  lead  to  distortion,  if  not  interrupted,  and 
slight  paralysis  from  spinal  causes. 

Rachitis,  owing  to  increasing  means  of  differentiating  it 
from  other  forms  of  bone  deterioration,  is  becoming  better 
understood.  A  positive  proof  that  the  atonic  condition  of 
the  fibrous  (ligamentous  and  muscular)  structures  is  a  dif- 
ferent disordered  condition  from  rickets,  appears  to  be 
afforded  by  the  fact  that  the  in-knee  commonly  called 
statical  (as  distinct  from  rachitic),  and  which  we  prefer  to 
call  atonic,  originates  when  the  growth  is  most  rapid,  not  only 
in  early  infancy  and  childhood  at  the  age  and  during  the 
years  in  which  rickets  invariably  begins  and  ends  (distortion 
perhaps  remaining  unless  counteracted  by  art),  but  may 
originate  also  between  the  ages  of  five  and  twelve,  and 


78  IN-KNEE    DISTOllTION. 

especially  often  during  the  second  fast-growing  period  which 
precedes  puberty  (age  twelve  to  sixteen  or  seventeen),  when 
rachitis  does  not  originate.  We  believe  that  there  is  not  a 
single  fact  on  record  to  show  that  any  symptom  or  sign  of 
rickets  affecting  the  bones  (softening  and  subsequent  ebur- 
nation)  or  other  parts  of  the  frame  was  ever  observed  to 
originate  within  those  years.  We  would  enquire,  Who  has 
ever  seen  a  case  of  rickets,  such  as  figs.  32,  33,  and  34, 
originate  at  any  other  period  than  early  childhood  ?  There 
have  been  plenty  of  in-knees  without  bone  softening  and 
curvature,  such  as  fig.  5,  seen  to  originate  after  childhood, 
but  these  we  have  shown  are  non-rachitic.  We  are  aware 
that  several  most  able  men  believe  they  have  seen  rickets 
originate  during  adolescence,  because  they  have  seen  statical 
non-rachitic  knock-knee  produced  at  that  period,  but  they 
have  assuredly  been  mistaken. 

We  consider  that  no  pathologist  will  deny  that  unequi- 
vocal rachitis  exhibits  distinct  stages,  that  these  stages  run 
a  definite  course  as  to  time  and  as  to  the  nature  of  the  bone 
I  and  constitutional  changes  ;  and  the  osseous  system,  which 
has  once  traversed  the  ordinary  rachitic  stages,  has  never 
been  known  to  traverse  these  stages  a  second  time,  differing 
in  this  respect  from  somewhat  analogous  bone  changes 
which  occur  in  another  disorder,  scorbutus. 

Another  fact,  which  confirms  the  identity  of  the  non- 
rachitic genu-valgum  of  early  infancy,  and  that  which 
begins  at  impending  adolescence,  is  that  a  child  may  be 
practically  cured  of  this  form  of  knock-knee  in  infancy,  and 
yet  if  subjected  to  the  causes  of  non-rachitic  knock-knee 
(pp.  8,  65),  during  the  extra  rapid  growth  of  approaching 
adolescence,  the  complaint  may  return,  whereas  no  one 
has  ever  seen  a  once  softened  and  curved,  then  afterwards 
straightened  and  eburnated  rickety  bone,  soften  and  bend 
a  second  time. 

It  should  be  noted  that  atonic  knock-knee,  as  we  have 


EICKETS    NOT    A    RECUREENT    DISEASE.  79 

shown,  may  originate  during  adolescence,  and  that  atonic 
in-knee,  if  existing  before  adolescence,  and  rachitic  in-knee 
may  become  greatly,  and  often  very  suddenly,  aggravated 
by  undue  standing  and  walking,  and  weight  carrying,  at 
that  age.  The  changes  at  this  age  are  at  the  joints  only 
in  atonic  knock-knee,  and  even  in  rachitic  cases  the  aggra- 
vation is  sometimes  more  in  the  joints  than  in  the  bones. 
Although  eburnated  bones  are  doubtless  less  inclined  to 
bend  than  normally  ossified  bones  of  that  age,  yet  eburnated 
and  much  distorted  bones  may  not  be  able  to  resist  further 
bending  at  any  age  when  exposed  to  the  influence  of  gravity 
so  disadvantageously  applied,  as  in  the  case  of  individuals 
whose  bones  are  already  curved  having  to  bear  the  burden 
of  relatively  heavy  weights  and  over-standing  and  walking.' 
Such  persons  can  only  be  correctly  described,  pathologically 
and  symptomatic  ally,  as  persons  affected  with  rickety  dis- 
tortio7i  caused  by  rickets  in  early  childhood,  now,  i.  e.,  in 
adolescence,  becoming  aggravated  by  statical  influences.' 
They  cannot  be  correctly  termed  the  subjects  of  rickets 
(cachexia,  or  dyscrasia  rachitica),  for  that  disease  subsided 
in  childhood,  certainly  before  the  age  of  five  or  six  years. 
Observation  shows  that  bones  which  have  once  reached  the 
stage  of  eburnation  do  not,  as  we  have  already  said,  again 
soften ;  the  increase  of  deformity  during  adolescence  mainly, 
if  not  exclusively,  depending  upon  yielding  at  the  joints, 
and  not  in  the  already  curved  shafts  of  the  bones.  The 
sudden  appearance  of  atonic  knock-knee,  or  of  comparatively 
sudden  aggravation  of  pre-existing  slight  rachitic  distortion, 
have  misled  physicians  to  the  belief  that  rickets  may  origi- 
nate in  late  childhood  and  adolescence. 

Severe  rickets  affords  the  most  intractable  of  the  causes 
of  in-knee,  when  the  constitutional  disorder  and  the  local 
condition  have  been  neglected  in  the  early  stage.  A  state 
of  more  or  less  complete  rachitism  is  a  frequent  cause 
also  of  the  inability  of  infants  to  stand  or  run  properly 


80  IN-KNEE    DISTORTION. 

alone  at  the  ordinary  age  when  unaided  proper  locomotion 
is  effected,  ^ny  from  the  tenth  to  the  fifteenth  month.  It  is 
unnecessaiy  in  this  paper  to  enter  fully  into  the  pathology 
of  rickets,  but  we  may  he  permitted  to  reprint  some  remarks, 
published  by  one  of  us  in  a  course  of  lectures  in  the  '  Lancet,' 
in  18J:2-3,  introductory  to  the  subject  of  in-knee,  and  its 
commonly  associated  complaint,  flat-foot.  "  In  relation  to 
distortions  the  important  feature  of  rickets  is  that  of  soften- 
ing the  bony  frame-work  of  the  sj'stem ;  hence  a  sinking  of 
certain  parts  beneath  the  superincumbent  weight,  and  a 
liability  to  alteration  from  the  natural  shape  through  the 

action  of  the  muscles  attached  to  them Piickets  is  not 

solely  a  disease  of  the  osseous  system,  but  its  effects  are  in 
this  part  more  obvious,  and  therefore  have  been  longer 
noticed.  Our  own  opinion  is  that  every  tissue  of  the  frame  is 
involved  in  the  loss  of  tone  and  firmness, — the  bones,  the  liga- 
ments, the  involuntary  and  voluntary  muscles  and  their  ap- 
pendages the  membranes,  glandular  (the  chylopoietic)  organs, 
and  the  nervous  system.  The  precursory  signs  of  rickety  dis- 
tortions, consisting  of  slightly  enlarged  head,  weakness  of 
loins,  pallid  face,  flabby  though  bulky  limbs,  tardy  dentition, 
tumid  abdomen,  with  continued  liability  to  bronchial,  gas- 
tric and  intestinal  derangements,  manifest  themselves  from 
the  sixth  to  the  twefth  month.  Soon  the  wrists  begin  to 
enlarge  (add  here  the  chondro-costal  junctions  to  swell),  the 
ribs  to  flatten,  the  bones  of  the  lower  extremitios  to  be 
slightly  curved,  and  the  child  remains  incapable  of  stand- 
ing ;  deformity  is  already  apparent.  In  a  more  advanced 
stage  more  numerous  articulations  become  distorted,  the 
inner  ankles  sink  beneath  the  weight  of  the  body,  the  knees 
'knock'  together,  the  thigh  and  leg  bones  curve,  flexion  of 
the  pelvis  upon  the  thighs,  and  curvature  of  the  lumbar 
vertebrae  forwards  (lordosis),  ensue." 

It  will  facilitate  the  student's  diagnosis  between  the 
atonic  and  rickety  in-knee  if  in  this  place  we  picture  the 


SIGNS    OF    EXTREME    RICKETS. 


81 


Fig.  30. 


most  extreme  form  of  rickets ;  for  when  acquainted  with 
the  strong  featm-es  of  well-marked  rickets  he  may  be  enabled 
to  discover  one  or  more  of  its  acknowledged  signs.  Be  the 
traces  even  slight,  he  will  be  justified  in  classing  the  in-knee 
as  of  rickety  origin,  whether 
or  no  the  actual  rickety  dys- 
crasia  have  been  recovered 
from,  and  distortion  only  re- 
main. 

Two  facts  respecting  ra- 
chitis have  been  known  to 
clinical  observers  from  the 
time  of  Glisson  to  the  present 
day.  (1)  That  the  tendency 
of  rickets  is  to  shorten  the 
stature,  to  give  to  the  head  a 
disproportionate  largeness,  to 
narrow  and  flatten  the  chest 
from  side  to  side,  to  arch  the 
clavicles  upwards  and  for- 
wards, to  produce  protube- 
rance of  the  belly,  excessive 
length  of  the  arms,  dispropor- 
tionate shortness  of  the  lower 
limbs,  and  curvatures  of  the 
long  bones,  especially  in  the 
legs,  seldom  without  some  in- 
knee  deviation.  The  whole  of 
these  changes  are  well  shown 


Extreme  in-knee,  loith  bone  curva- 
tures, rachitic,  and  dispropor- 
tionate groiotli  of  parts  in  an 
adolescent,  aged  seventeen,  the 
whole  height  being  little  more 
than  four  times  the  length  of  the 
head.  (From Little ,  on  '■Deformi- 
ties of  the  Human  Frame.^  1853.) 


in  fig.  30.  (2)  That  rickets 
commonly  affects  the  bones  of  the  lower  extremities  to  a 
greater  degree  than  those  of  the  upper  part  of  the  trunk. 
It  is  quite  certain  that  rachitic  distortions  are  more 
frequent  and  more  considerable  in  the  lower  extremities 
than  in  the  upper ;  yet  it  might  be  that  rickety  distortions 

M 


82 


IN-KNEE    DISTORTION. 


Fig.  31. 


impress  the  senses  and  mind  of  the  ohserver  to  a  greater 
extent. than  the  constitutional  and  more  concealed  pheno- 
mena of  the  disease,  and  therefore  might  have  led  to  an 
erroneous  conclusion  that  rachitism  ma}^  affect  earlier,  and 

to  a  greater  degree,  the  hones  of  the 
lower  extremities  than  those  of  the 
upper. 

Our  experience  and  helief  is  that 
the  statements  are  facts.  We  have 
only  to  look  at  an  extreme  subject  of 
rachitis  who  has  completed  growth 
to  note  the  disproportionate  length 
of  the  trunk  compared  with  the  ex- 
tremities, and  that  often  the  lower 
limbs  alone  are  appreciably  affected 
with  deformity. 

Annexed  is  a  figure,  from  Bou- 
vier   (ojj.  cit.),  of  a   female,  aged 
sixty-nine,  with  extreme  rickety  dis- 
tortion of  the  lower  extremities,  and 
considerable  rachitic   spinal  curv- 
ature, whose  entire  height  did  not 
exceed  a  metre  ;  but  for  the  spinal 
curvature  it  would  have  been  a  few 
inches  greater.    The  view  of  such  a 
case  suggests  the  belief  that  this 
individual,  having  being  seized  with  rachitis  at  a  very  early 
period  of  existence,  probably  intra-uterine,  has,  as  regards 
the  proportionate  size  of  the  upper  extremities  and  trunk 


Extreme  rachitic  arrested  de- 
reJopment  of  the  lower  ex- 
tremities in  a  female* 


-'■  When  tlie  like  of  the  above  is  extruded  from  the  uterus  before 
its  time  our  German  friends  name  it,  "mikromehe;"  or  when  the 
uterine  product  exhibits  the  extreme  of  rachitic  mikromelie  they 
designate  it,  "  phokomehe."  If  the  product  slioukl  survive  to  seventy 
years  the  term  myle,  mola,  or  mole,  would  not  be  very  applicable.  See 
Ui'tel:  '  Ueber  Eachitis  Congenita,'  Halle,  1873, 


EICKETS    A    SPECIFIC    DISEASE.  83 

and  the  lower  extremities,  remained  nearly  the  same  as  at 
the  commencement  of  the  disease.  In  fact  the  individual 
may  be  regarded  as  an  example  of  arrested  development, 
especially  of  the  lower  extremities,  from  rachitis.  The 
earlier  and  more  complete  the  rickets,  the  greater  the  arrest 
of  development  and  the  shorter  the  lower  extremities  will 
be  in  the  adult. 

We  have  shown  (pp.  16,  87)  how  considerable  in  the 
healthy  infant  is  the  growth  of  the  bones  of  the  lower  extre- 
mities during  the  earliest  months  of  life,  whereby  the  dis- 
proportionate shortness  of  these  parts  at  birth  is  removed. 
If  the  infant  comes  into  the  world  with  hereditary  rachitis, 
or  with  a  predisposition  to  it,  acquired  at  the  period  of 
impregnation  of  the  ovum,  or  imbibed  during  gestation,  the 
onset  of  a  disease,  one  of  the  essential  characters  of  which 
is  to  prevent  healthy  bone  development,  is  likely  to  be  first 
manifested  in  the  parts  of  the  osseous  system, — the  bones 
of  the  lower  extremities, — which  in  the  human  fcetus  are 
comparatively  small  before  birth,  and  which  in  the  norm 
undergo  a  remarkable  increase  of  growth  during  the  first 
few  months  of  life.  It  is  known  that  at  birth  the  vertebral 
column,  and  consequently  the  trunk,  is  naturally  long  com-  ( 
pared  with  the  lower  extremities.  It  is  also  known  that' 
the  vertebrse  are  less  apt  to  be  affected  with  rachitic  soften- 
ing and  subsequent  hardening  (eburnation)  than  the  "long" 
bones  of  the  lower  extremities. 

Despite  the  oft-reported  artificial  production  of  rachitis 
in  domestic  animals,  we  consider  it  doubtful  whether  this 
disease  is  ever  the  result  of  the  operation  of  its  predisposing 
and  determining  causes  in  a  single  generation,  whether  it 
be  not  always  hereditary,  whether  it  is  not  as  much  a  specific 
disease  as  syphilis,  cancer,  variola,  or  scarlet  fever.  Two  or 
more  children  of  the  same  parents  affected  with  rachitic  in- 
knee  are  often  seen;  but  amongst  well-to-do  people,  whether 
brought  up  at  the  breast  or  spoon-fed,  we  have  oftener  seen, 


84 


IN-KNEK    DISTORTION. 


we  believe,  a  single  distinctly  nicliitic  child  in  a  family 
where,, there  were  several  health}^  well-grown  brothers  and 
sisters,  than  we  have  seen  a  single  genu-valgum  in  a  large 
family  from  deficient  unsuitable  feeding,  owing  to  the 
absence  of  breast-milk  of  the  mother.  The  earliest  born 
children  of  a  mother  who  cannot  "nurse"  her  infant 
usually  suffer  often  est  from  non-rachitic  genu-valgum, 
whilst  our  belief  is  that  a  single  distinctly  rachitic  3'oung 
patient  has  often  been  one  of  the  later  born  of  a  numerous 
family. 

We  here   append  figures  (figs.  82  and  33)  of  the  best 
marked  rickety  enlargements  and  curvatures  of  leg  bones, 


Fig.  32. 


Fig.  33. 


Figs.  32,  33. — Typical  diiitortion  of  the  epiphysis  of  the  tibia  and  fihida  in 
rickety  distortion  often  accoinpanyiny  racliitic  in-Iaiee,  co-cxistiny  with  a 
similar  condition  of  the  icrists  and  1'ore-anns. 


and  of  abnormal  weakness  and  hollowness  of  loins  (lordosis), 
fig.  34,  apt  to  occur  in  ricket}^  subjects.  It  should,  how- 
ever, be  known  that  similar  hollowness  of  loins  may  arise 
from  other  local  or  constitutional  states  than  rickets,  namely, 


SIGNS    OP    RICKETS. 


85 


Fig.  34. 


atony  of  fibrous  structures,  paralysis  of  lumbar  muscles,  and 
from  congenital  and  acquired  lux- 
ation of  the  hip. 

Another  important  and  early 
sign  of  rickets  is  afforded  by  the 
globular,  more  or  less  bead-like 
swellings  formed  at  the  sternal  end 
of  the  ribs  at  their  junction  with 
the  cartilages  ("le  chapelet  rachi- 
tique."  See  Guerin  and  Bouvier, 
op.  cit.).  Any  trace  of  such  swell- 
ings in  a  case  of  in-knee  proclaims 
its  rachitic  character. 
j  Nor  should  examination  of  the 
teeth,  especially  of  the  second  set, 
be  omitted,  as  these  often  display 
the  rachitic  character  of  parallel 
horizontal  lines  of  enamel  taking 
the  place  of  an  uniform  layer  of 
this  hard  material,  the  deficiency 
being  commonly  greater  at  the  cut- 
ting edge  of  the  tooth  than  towards 

its  root,  and  in  extreme  cases  both  the  sets  being  extremely 
deficient  in  hard  matter,  and  being  many  of  them  shed 
soon  after  they  pierce  the  gums. 

In  order  to  further  understand  the  bearing  of  these  facts 
upon  the  diagnosis  of  non-rachitic  from  rachitic  knock-knee, 
it  will  be  necessary  to  dwell  for  a  moment  upon  the  normal 
condition  of  the  lower  limbs  during  the  later  months  of 
pregnancy,  and  the  normal  development  of  these  parts 
during  the  first  months  and  years  of  life,  and  compare  this 
normal  state  of  things  with  the  abnormal  state  of  things 
introduced  by  the  rachitis. 

Any  surgeon,  familiar  with  the  treatment  of  congenital 
club-foot  during  the  earliest  weeks  and  months  of  the  child's 


Lordosis,  believed  in  tliis  case 
to  he  due  to  atonic  relaxation, 
and  not  to  rickets. 


86  IN-KNEE    DISTORTION. 

life,  will  have  been  struck  with  the  fact,  already  mentioned, 
that  an  extemporised  splint  of  any  inextensible  material 
fitting  during  the  first  fortnight  or  month  becomes  uselessly 
short  during  the  second  fortnight  or  month,  and  that  this 
experience  is  repeated  every  few  weeks  afterwards ;  and 
every  nurse  takes  pleasurable  notice  of  the  rapid  growth  of 
healthy  non-distorted  limbs  at  this  period  of  life. 

Every  parent  with  a  large  family  of  sons  has  known  too 
well  the  economic  difficulty  of  keeping  fast-growing  boys 
supplied  with  trowsers  of  sufficient  length  from  the  age  of 
about  thirteen  to  seventeen,  and  the  physiologist  is  aware 
that  at  this  age  the  previous  disproportionate  length  of  the 
trunk  is  rapidly  balanced  by  the  uncommon  rapid  develop- 
ment in  length  of  the  lower  limbs  at  that  age,  in  order  that 
by  the  end  of  adolescence  the  individual  destined  to  be,  say, 
for  example,  six  feet  high,  shall  measure  upwards  and  down- 
wards from  the  trochanters  each  way  three  feet.  Indeed, 
there  seems  a  time  between  thirteen  and  seventeen  when 
the  proportions  in  the  length  of  the  trunk  and  lower  extre- 
mities are  for  a  time  only,  even  the  reverse  of  the  state  of 
things  at  birth,  for  at  birth  the  trunk  is  relatively  long  com- 
pared with  the  lower  extremities,  whilst  during  adolescence 
the  proportions  in  non-rachitic  individuals  are  apt  to  be 
reversed.* 

A  large  and  long  male  infant,  the  first-born  of  the 
family,  destined,  as  the  result  showed,  to  be  over  six  feet 
high  when  growth  was  completed,  weighed  at  birth  twelve 
pounds,  and  measured  twenty-two  inches  in  length.  At 
three  years  old,  agreeing  with  the  commonly  received 
opinion  that  at  that  age  half  of  the  ultimate  height  would 
be  attained,  this  child  measured  something  over  thirty-six 
inches,  and  was  seen  by  one  of  us  on  account  of  the  appear- 
ance of  slight  double  (atonic)  in-knee.    During  three  years, 

*  See  Alexander  Shaw :  article,  "  Kickets,"  'Holmes's  System  of 
SiU'gery,'  2nd  edition. 


RATE    OF    GROWTH    IN    MAN.  87 

up  to  this  time,  he  had  grown  at  an  average  rate  of  four 
inches  and  two-thirds  annually.  But  as  seven  inches,  one- 
third  of  the  growth  at  birth,  were  probably  added  to  the 
growth  during  the  first  year  (see  p.  16),  the  growth  during 
the  second  and  third  years  amounted  to  about  seven  inches 
in  these  two  years.  He  became  six  feet  high  at  twenty-one, 
and  did  not  cease  growing  until  twenty-three,  when  he 
attained  the  height  of  six  feet  one  inch  and  a  half.  Between 
the  age  of  three  and  twenty-one  he  had  only  grown  thirty- 
six  inches,  an  average  of  two  inches  per  annum.  As  it  is 
certain  that  he  grew  rapidly  soon  after  the  commencement 
of  adolescence,  there  were  years  before  adolescence  and 
during  the  later  part  of  adolescence  during  which  the  growth 
will  have  been  less  than  two  inches  yearly.  We  are  without 
sufficient  data  for  the  average  growth  of  healthy  boys  and 
girls  between  the  ages  of  thirteen  and  seventeen.* 

-''  Since  the  remarks  on  the  rate  of  growth  in  infants  (on  p.  17)  were 
printed,  we  have  been  favoured  with  the  following  observation  on  the 
growth  of  a  healthy  male  infant,  born  in  November  last,  the  first  child 
of  the  marriage,  nursed  entirely  at  the  mother's  breast,  and  which  has 
had  no  appreciable  health  disturbance  since  birth,  viz. : — 

Weight  at  birth,  5^  lbs.  (about)         .         .         .        Length,  17-g  in. 
,,      ,,  age  of  one  calendar  month,  11  lbs. 

(accurately  weighed)    ...  ,,       21     ,, 

,,      ,,  age  of  two  calendar  months,  12  lbs. 

4  oz.  (accurately  weighed)  .         .  ,,       23J  ,, 

,,      ,,  age  of  three  calendar  months,  15  lbs. 

(accurately  weighed)    ...  ,,       23f  ,, 

It  wiU  be  interesting  and  useful  if  some  young  obstetricians  will  accu- 
rately weigh  and  measiu'e  a  series  of  infants  at  regular  monthly  intervals 
during  the  first  eighteen  months,  and  subsequently  at  annual  intervals, 
and  note  any  apparent  variations  of  the  rate  of  growth  caused  by  suc- 
cessive changes  of  diet,  town  or  country  residence,  or  by  illness  of  any 
kind.  The  date  of  "running  alone,"  also  the  date  of  commencement 
of  any  illness  or  distortion,  and  its  duration,  would  tend  to  advance 
the  knowledge  of  the  disorders  and  diseases  of  childhood.  Tliis  appli- 
cation of  "  the  numerical  method  of  medicine"  would  also  afford  pre- 
cise data  respecting  the  effect  of  acute  illness  and  recumbency  in 
accelerating  length  during  advanced  childhood  and  adolescence. 


88  IN-KNEE    DISTORTION. 

It  is  certain  that  the  greater  niimher  of  atonic  cases  of 
ih-knee  arise  at  the  two  periods  at  ^Yhich  the  most  active 
physiological  evolution  of  the  hones  of  the  lower  extremity 
take  place,  the  first  period  extending  from  birth  to  the  age 
of  three  or  four  years,  and  the  second  period  coinciding 
with  that  of  puberty  (age  twelve  to  seventeen).  Eachitic 
disease,  it  is  equally  certain,  is  confined  to  the  first  of  these 
periods,  although  distortion  may  remain  and  possibly  in- 
crease through  the  influence  of  gravity  (see  p.  79).  Infantile 
rachitic  curvatures  of  the  lower  limbs  with  in-knee  are 
brought  to  us  at  the  same  period  of  life  as  the  non-rachitic  ; 
but  it  will  be  found  on  investigation  that  many  of  these 
children  had  signs  of  rachitis  at  birth,  or  very  soon  after- 
wards, and  were  not  brought  to  us  for  advice  until  the 
deformity  was  more  glaring,  and  the  parents  had  lost  the 
hope  of  "  the  child  out-growing  it." 

These  observations  on  growth  lead  to  the  last  point  of 
distinction  between  in-knee  of  simple  debility  from  rela- 
tive over-exertion  in  proportion  to  strength  (genu-valgum 
atonicum,  staticum), — which  occurs  pre-eminently  in  fully 
proportioned,  long-boned,  fast-growing,  tall  infants  and 
adolescents, — and  in-knee  from  the  specific  disease,  rachitis, 
which  tends  to  arrest  growth,  shorten  the  bones,  and  present 
distortion  in  comparatively  short-limbed  individuals,  conse- 
quently of  ultimate  comparatively  short  stature,  and  which 
begins  and  ends  in  infancy,  i.  e.,  before  the  age  of  five  or 
seven  years. 

In  the  diagnosis  between  rachitic  and  non-rachitic  de- 
formities it  may,  during  infancy,  practically  suf&ce  to  regard 
as  non-rachitic  those  cases  which  present  no  signs  of  rachitis 
in  other  parts  of  the  economy.  The  first  appearance  of  in- 
knee  during  adolescence,  say  from  the  twelfth  or  thirteenth 
to  the  sixteenth  year,  seeing  that  rachitis  never  originates 
during  those  years,  is  conclusive  evidence  that  we  have  to 
deal  with  a  non-rachitic  affection.     Macewen  and  others, 


RACHITIS   VERSUS    MOLLITIES    OSSIUM.  89 

who  assert  that  they  have  witnessed  the  origin  of  rachitis 
after  childhood,  have  been  misled  by  the  a  priori  notion 
that  all  cases  of  knock-knee  are  due  to  rachitis.  We  have 
never  seen  rickets  and  its  consequent  curvatures,  combined 
with  genu-valgum,  originate  after  infancy.  We  have  never  i 
even  seen  a  case  of  rachitis  after  the  age  of  four  or  five 
years,  for  by  that  age  the  natural  transition  from  softening 
to  undue  hardening  has  fully  set  in.  The  deformities 
from  curvature  of  bones  and  yielding  of  knee  joint  may 
remain,  but  these  are  the  effects  of  disease,  and  not  the 
rachitis  itself.  We  have  seen  rare  cases  of  mollities  and 
fragilitas  ossium  originate  during  later  childhood  and 
puberty,  but  these  cases  are  acknowledged  by  pathologists 
to  be  distinct  from  rachitis.  As  far  as  we  have  observed 
these  cases  have  not  recovered,  have  never  been  succeeded 
by  a  stage  of  eburnation,  which,  as  is  well  known,  is  the 
spontaneous  mode  of  termination  of  rachitism. 

Bouvier  (op.  cit.,  p.  314)  says :  "On  est  souvent  dispose 
a  attribuer  a  la  seule  action  du  poids  du  corps  les  courbures 
des  jambes  qui  affectent  des  enfants  jouissant  en  apparence, 
d'une  sante  florissante.  J'ai  presque  toujours  trouve  ches 
ces  enfants  quelques  traces  de  rachitisme,  le  chapelet  par 
exemple.  J'en  dirai  autant  des  deviations  du  genou." 
Bouvier  regards  the  "chapelet  rachitique"  as  the  patho- 
gnomonic sign  of  the  first  stage  of  rickets.  We  should  place 
nodes  at  the  ends  of  the  bones  of  the  extremities  in  the 
same,  if  not  in  a  higher,  rank  of  signs. 

Broca,  as  quoted  by  Bouvier,  op.  cit.,  p.  292  ('Eecherches 
sur  le  Eachitisme,'  Paris,  1852),  says  that  "toutes  choses 
egales  d'ailleurs,  le  rachitisme  affecte  principalement,  a  son 
debut  et  pendant  sa  duree,  les  regions  qui  offrent  la  plus 
grande  activite  de  developpement  aux  epoques  corre- 
spondantes  de  I'etat  physiologique  tandis  que  les  os  dont  le 
plus  grand  developpement  est  anterieur  ou  posterieur  a 
I'invasion  de  la  maladie  en  ressentent  moins  les  effets." 

N 


90  IN-KNEE    DISTORTION. 

Tliese  views  of  Broca  support  the  opinion  of  Giierin  that 
tlu'  bones  of  the  lower  extremities  are  earher  and  more 
severel}'  affected  with  rickets  after  birth  than  those  of  the 
trunk,  and  that  the  first  signs  therefore  of  rickets  would  be 
found  in  the  lower  extremities.  We  have  no  data  as  to  the  rate 
of  growth  of  the  ribs  compared  with  the  bones  of  the  lower 
extremities.  From  the  known  capacity  of  the  chest  to  enter 
upon  the  act  of  respiration  immediately  after  birth,  we  pre- 
sume that  the  ribs  like,  the  vertebral  column,  are  relatively 
more  developed  at  birth  than  the  lower  extremities,  so  that 
if  rachitis  be  apt  to  show  itself  earliest  in  those  bones 
which  in  the  norm  should  be  most  actively  occupied  in 
physiological  development,  we  should  expect  to  find  the 
first  signs  of  rickets  in  the  ankles  and  legs.  By  the  time, 
however,  children  are  brought  to  us  we  commonly  find 
beads  of  enlargement  on  the  anterior  ends  of  the  ribs, 
whenever,  in  a  rachitic  infant,  we  look  for  them. 

In  diagnosis  between  non-rachitic  in-knee  and  the 
rachitic  form  it  is  well  to  remember  that  the  apparent 
degree  of  the  knee  distortion  is  augmented  in  rachitic  cases 
by  the  frequent  curving  inwards  of  the  femur  at  its  lower 
third,  and  of  the  tibia  at  its  upper  two-thirds.  These  curv- 
atures, if  not  considered,  may  lead  the  surgeon  to  over- 
estimate the  true  amount  of  knee  joint  inversion ;  for  we 
have  shown  in  the  preceding  pages  that  in-knee  may  exist 
without  curvature  of  the  bones.  It  may  even  be  safely 
asserted  that  the  inward  inclination  of  the  knee  joint  itself 
is  greatest  in  the  cases  in  which  no  rachitis  exists.  A  glance 
at  fig.  2  and  fig.  3,  and  fig.  15,  representing  cases  of  in-knee 
unconnected  with  rachitis,  is  conclusive  on  this  point. 

Some  modern  surgeons,  as  we  have  already  stated,  have 
wrongly  confined  the  term  genu-valgum  to  rachitic  cases. 
(See  p.  20.)  If  b}^  genu-valgum  is  meant  inward  inclina- 
tion of  the  knee  joint,  the  term  should  rather  be  confined  to 
the  non-rachitic  forms.     Bad  cases  of  rachitic  knock-knee, 


IN-KNEE    FROM    ACCIDENT.  91 

with  curvature  of  thigh  and  leg  bones,  would  be  more  cor- 
rectly termed  rachitic  curvatures  of  those  bones  with  genu- 
valgum. 

Another  point  of  difference  between  non-rachitic  and 
rachitic  cases  follows  as  a  consequence  of  the  absence  of 
curvature  of  bones  in  the  former,  namely,  that  in  these, 
apart  from  the  inversion  of  the  knee  joint  structures,  the 
contour  of  the  thigh  and  leg  are  unaffected :  these  parts 
remain  as  symmetrical  as  they  were  before  the  genu- 
valgum  took  place,  as  may  be  seen  in  the  reduced  copies  of 
outlines  of  the  limbs  affected  with  in-knee,  taken  some 
years  before  the  discovery  of  photography,  by  passing  a 
pencil  around  the  child's  limbs  whilst  he  lay  recumbent 
on  a  sheet  of  paper,  fig.  11.  Fig.  15,  copied  from  Mayer, 
which  was  not  published  in  support  of  my  argument, 
illustrates  the  same  fact.  Volkmann  {op.  cit.,  p.  720) 
describes  an  interesting  case  of  in-knee  following  some  long 
time  after  traumatic  injury  of  a  limb.  "We  have  the  photo- 
graph of  an  adult  who,  after  reunion  of  a  fractured  tibia  and 
fibula,  became  affected  with  considerable  in-knee,  requmng 
months  of  mechanical  treatment  before  it  could  be  securely 
cured. 

Another  point  of  distinction,  however,  is  that  non- 
rachitic in-knee  may  be  cured  in  the  young  child  in  a  few 
weeks  or  months,  whilst  the  changes  required  to  be  effected 
in  the  rachitic  constitution  for  its  cure,  and  the  arrest  and 
permanent  removal  of  the  attendant  curvatures  of  the  thigh 
and  leg  bones,  which  so  much  intensify  the  genu-valgum,  is 
often  a  matter  of  months  or  years.  i 

However  distinctly  severed  the  pathology  of  ordinary 
infantile  paralysis  is  from  that  of  rachitis,  there  is  no 
a  priori  reason  why  they  should  not  accidentally  co-exist. 
Fig.  35  represents  the  co-existence  of  infantile  paralysis  of 
lower  extremity  with  slight  genu-valgum,  without  curvature 
of  leg  bone.     So  rare  is  the  co- existence  of  two  distinct 


92 


IN-KNEE    DISTOKTION. 


forms  of  disease  in  the  same  individual  that  we  experience 
difficulty  in  assigning  the  true  pathology  of  the  case  repre- 
sented (tig.  36).  This  case  stood  in  Little,  '  On  Deformities,' 
1853,  p.  229,  as  a  case  of  genu-valgum  with  paralytic  varus. 

At  that  period  we  regarded 

Fig.  3o.  " 

the  bone  curvature  to  be 
due  to  rickets.  We  do  not 
remember  having  met  with 
other  cases  of  paralysis  and 
rickets  in  conjunction,  even 
if  not  of  simultaneous  ori- 
gin. This  case  and  that 
copied  from  Mayer,  on  page 
20  of  this  work,  suggest 
the  thought  whether  in 
bone  curvature  the  yield- 
ing of  the  leg  beneath  the 
superincumbent  weight  of 
the  trunk  may  not  often 
take  place  at  the  junction 
of  the  upper  epiphysis  of 
the  tibia  with  the  shaft 
of  the  bone.  If  the  case, 
fig.  36,  be  not  rickety,  then, 
as  the  paralysis  was  espe- 
cially severe  in  the  leg  and  foot,  the  attenuated  bones  of 
the  leg,  wasted  by  the  paralytic  want  of  organic  nutrition, 
may  have  yielded  to  gravity  during  the  struggles  of  the  in- 
dividual to  effect  locomotion  upon  it. 

In  fig.  37,  where  the  paralytic  in-knee  is  most  severe, 
so  much  so  as  to  have  compelled  resort  to  crutches,  although 
the  tibia  is  extremely  slender,  there  exists  no  bone  curvatui-e, 
because  the  effects  of  gravity  could  not  come  into  operation. 
Fig.  38  shows  a  much  greater  amount  of  knee  inclina- 
tion, with  considerable  knee  contraction  in  the  direction  of 


HU(jlit paralytic  riijht  lower  extremity,  with 
diyht  f/enu-valtiuin  and  eqnino-varU'i. 


IN-KNEE    FROM    PARALYSIS. 


93 


Fig.  3G. 


flexion,  in  a  child  affected  with  very  general  spastic  rigidity 
and  contraction  of  muscles,  fol- 
lowing  upon   asphyxia   neonato- 
rum,   sometimes    the   result   of 
abnormal  parturition. 

It  will  be  remarked  that  in 
the  first  of  these  paralytic  cases 
the  in-knee  deviation  is  very 
slight.  The  distortion  is  the  na- 
tural consequence  of  the  para- 
lysis having  been  sufficiently 
severe  to  interfere  greatly  with 
walking.  In  the  ordinary  atonic 
and  ordinary  rachitic  in-knee  the 
volition  of  the  individual,  with 
advancing  age,  is  strong,  and 
prompts  to  considerable  use  of 
the  affected  limbs,  until  in  fact 
with  great  increase  of  deformity 
the  labour  and  pain  of  walking 
may  lead  finally  to  its  abandon- 
ment. With  paralysis  of  limbs, 
however,  affecting  the  muscles  of 
both  the  knee  and  the  leg,  any 
considerable  amount  of  sponta- 
neous locomotion  is  impossible, 
especially  when  the  knee  has 
once  given  way  inwards ;  con- 
sequently in  paralysis  the  in- 
ward inclination  never  attains 
any  considerable  degree. 

The  contrary  is  the  case, 
however,  in  cases  of  the  lower 
limbs  contracted  from  spasm, 
fig.  38.     Here   the    obstacle   to 


Severe  paralysis  of  lower  extre- 
mity xoith  slight  in-hnee  devi- 
ation, paralytic  equino-variis 
contraction,  and  slight  ticist 
{rachitic  ?  or  merely  statical  ?) 
in  the  leg  bones. 


94 


IN-KNEE   DISTORTION. 


Fig.  37. 


locomotion  is  not  the  weakness  of  paralysis,  but  the  stiff- 
ness, rigidit}'  and  contraction  of  muscles  ill  co-ordinated, 
disturbed  by  choreic  irritability,*  the  knee  joints  and  ankle 
being  brought  after  a  few  years  into  a  state  of  constant 

contracture,  and  structural  or 
adapted  shortening.  In  these 
cases  nutrition  and  gro"ui;li  of 
muscle  are  superior  to  those  of 
the  paralysed  limb ;  the  patient 
takes  exercise  in  a  peculiar 
jerky  stiff  characteristic  un- 
sightly manner,  yet  contrives 
to  take  a  good  deal  of  it ;  hence 
the  effect  of  superincumbent 
weight  is  more  operative,  and 
leads  to  a  larger  amount  of  in- 
knee.  This  kind  of  lameness 
and  its  pathology  were  dis- 
covered by  us  before  1842. 
See  lectures  in  the  'Lancet,' 
1842-3.  Obstetrical  Soc.  Trans. 
1868. 

From  the  example  of  the 
occurrence  of  distortion  in  pa- 
ralytic limbs  (see  figs.  35,  36, 
37),  in  which  the  proper  anta- 
gonism of  the  several  classes  of  muscles  has  been  anni- 
hilated, we  know  that  a  particular  muscle  may  obtain  a 


Moat  severe  paralytic  fienu-valrjuvt 
ivith  most  severe  foot  contraction 
From  Little,  '  On  Deformities.' 


■■'  Such  cases  are  not  real  chorea,  though  often  erroneously  desig- 
nated congenital  chorea.  A  sudden  noise,  fear  of  falling,  unexpected 
touch  of  the  skin,  a  puff  of  air,  or  other  cause  of  eraotiou,  or  of  centri- 
petal cerebro-spinal  influence,  will  excite  increase  of  contraction  and 
of  jerking  of  the  affected  limbs.  Instead  of  instability,  or  mere  want 
of  co-ordination,  we  prefer  the  term  choreic  irritability,  which  describes 
better  the  condition  of  such  patients. 


STRUCTURAL    SHORTENING    OF    MUSCLES. 


95 


Fig.  38. 


preponderance  over  others  (not  necessarily  a  sjmsni  of  it, 
although  in  certain  cases  the  distortion  is  due  to  spasm,  as 
already  said,  when  it  occurs  in  children  who  have  suffered 
from  asphyxia  neonatorum).  When,  therefore,  in  a  given 
case,  we  see  reason  to  reject  the  sole 
influence  of  weight  of  the  body,  as 
well  as  rickets,  paralysis  and  spasm 
in  producing  the  distortion,  we  are 
thrown  hack  upon  that  contraction 
of  previously  healthy  muscle  which 
is  apt  to  ensue  when  the  points  of 
insertion  of  muscles  are  loosened, 
and  their  leverages  changed  by  a 
general  weakness  of  the  joint  struc- 
tures, such  as  we  have  stated  to  exist 
in  ill-nourished  children.  The  mus- 
cular contraction  in  question  has 
been  of  long  duration,  and  has 
adapted  the  muscles  to  its  shortened 
length,  when  they  may  remain  an 
obstacle  to  cure  (structural  shorten- 
ing). Formerly,  on  account  of  this 
shortening,  we  resorted  frequently  in 

these   cases  to   section  of  the   biceps   Flexion,  with  hwck-knees  and 

femoris,  and  any  neighbouring  tense      '''''''  '^^^'^'f''^  'P^'^' 

contraction.    From  Little, 

fascial  and  ligamentous  structures.      .  ^^^  Deformities ' 
The   resistance    to    rectification    of 

form  is  felt  to  proceed  from  the  structures  on  the  outer 
side  of  the  articulation,  the  biceps  tendon,  and  probabl}^  the 
subjacent  external  lateral  ligament. 

It  has  been  seen  from  the  above  (fig.  36)  that  a  paralytic 
in-knee  may  be  associated  with  curved  leg  bones.  Whether 
this  curvature  springs  from  weakness  of  bone,  owing  to 
such  impairment  of  nutrition  and  thinning  of  the  bone  as 
usually  accompanies  paralytic  wasting  and  contraction  of 


96  IN-KNEE    DISTORTION. 

muscles  (see  p.  48),  or  whether  it  be  clue  to  rachitism,  can 
only  he  proved  by  minute  anatomical  demonstration  (see 
p.  57).  The  balance  of  evidence  is  in  favour  of  simple 
wasting  and  thinning  and  yielding  of  the  bone  under  statical 
influence.  The  commencement  of  the  curvature  after  the 
age  of  early  childhood,  say  after  the  age  of  five  or  six  j'ears, 
when  the  paralysis  has  already  existed  several  years,  and 
the  absence  of  rickety  sj^mptoms  elsewhere,  constitute,  in 
our  opinion,  conclusive  evidence  against  a  rickety  origin. 
Occasionally  in  genu-valgum,  whatever  its  origin,  we  have 
known  "  strumous"  knee  set  up  after  a  fall.  We  have  also 
seen  "  knee  disease"  set  up  as  the  consequence  of  injudicious 
violent  methods  of  treatment  employed  for  the  rectification 
of  genu-valgum.     See  section  on  treatment. 

The  illustrations  of  knee  ankylosis  (figs.  24,  25,  26)  and 
strumous  knee  contraction  show  the  varied  and  complicated 
states  of  disturbance  of  form  and  position,  of  which  the  con- 
tracted and  more  or  less  completely  ahkylosed  knee  joint  is 
made  up.  Fig.  25  represents  a  knee  affected  with  true  or 
bony  ankylosis  in  the  position  of  slight  flexion,  considerable 
subluxation  backwards  and  outwards  of  the  head  of  the 
tibia,  marked  inward  inclination  of  the  knee,  with  a  corre- 
sponding marked  abduction  of  the  tibia.  The  ankylosis  is 
completed  by  ossification  of  the  patella  to  the  external  con- 
dyle. The  points  of  similarity  of  this  specimen  to  ordinary 
in-knee,  except  as  regards  the  sub-luxation  and  the  anky- 
losis, are  apparent.  These  anatomical  preparations  are 
confirmatory  of  the  statement  made  (p.  2)  that  whenever 
the  connecting  structures,  which  in  health  firmly  bind 
together  and  retain  in  their  places  the  bony  components  of 
the  knee  joint,  the  femur,  the  tibia  and  the  patella  are 
weakened  and  relaxed  by  disease ;  whatever  may  be  the 
nature  of  the  disease,  the  joint  assumes  more  or  less  com- 
pletely the  form  of  genu-valgum,  unless  the  distortion  be 
counteracted  by  art. 


IN-KNEE    FROM    STRUMA   AND    RHEUMATISM.  07 

The  fig.  26,  p.  63,  drawn  from  the  living,  illustrates 
the  appearance  during  life  of  the  anatomical  arrangement 
shown  in  fig.  25,  the  difference  in  this  case  being  that  the 
long-standing  ankylosis  was  incomplete,  and  therefore  re- 
movable, probably  because  the  articular  disease  was  of  stru- 
mous character.  The  inversion  of  the  knee,  the  subluxation 
of  the  head  of  the  tibia,  the  abduction  of  the  shaft  of  this 
bone,  and  the  situation  of  the  patella  upon  the  external 
part  of  the  outer  condyle,  denoted  by  the  black  patch  in  the 
drawing,  are  the  same. 

At  page  64  some  observations  were  made  on  rheumatism 
in  connection  with  in-knee,  or,  more  properly  speaking,  in- 
knee  induced  by  rheumatism.  We  have  seen  many  patients, 
often  elderly  people,  with  chronic  knee  rheumatism  of  mode- 
rate degree  of  severity ;  others,  with  "  rheumatic  neuralgia," 
as  they  termed  it,  with  exquisite  suffering.  Usually  there 
was  present  in  these  cases  some  serous  effusion  (synovitis 
serosa)  in  the  bursa  beneath  the  ligamentum  patellae,  or 
within  the  joint  itself.  Such  patients  were  accustomed  to 
be  driven  out,  and  hobbled  about  with  the  assistance  of  one 
or  two  sticks.  It  often  has  appeared  that  the  pain  and 
lameness  complained  of  were  out  of  proportion  to  the  actual 
amount  of  rheumatic  or  other  diseased  action  going  on  in  the 
part.  Usually,  as  in  most  knee  affections,  the  pain  has  been 
referred  to  the  inside  and  neighbouring  part  of  the  front  of  the 
internal  condyle.  It  is  worthy  of  remark  that  some  of  these 
long-suffering  patients  had  been  under  the  care  of  a  succes- 
sion of  able  men — who  probably  from  being  unaccustomed 
to  the  study  of  abnormal  changes  of  form  of  parts,  compre- 
hended under  the  name  of  distortions — had  apparently  failed 
to  observe  the  existence  of  some  degree  of  inward  inclina- 
tion of  knee,  for  they  had  omitted  to  take  any  therapeutic 
steps  to  correct  the  evil  of  it.  Owing  to  the  inversion  the 
normal  comparative  perpendicularity  was  infringed,  and  the 
pain  and  inconvenience  attending  even  awkward  attempts 

o 


98  IN- KNEE    DISTORTION. 

at  locomotion  were  ag,G;ravated.     See  the  section  on  treat- 
ment. 

As  a  further  anatomical  illuetration  of  the  universality 
of  the  production  of  the  prominent  features  of  genu- 
valgum,  when  from  any  cause  of  disease  the  knee  joint  is 
weakened  in  its  connections,  we  refer  to  the  representation 
(p.  64)  of  a  diseased  knee,  believed  to  have  originated  in 
rheumatism.  It  probably  commenced  with  ordinary  sub- 
acute serous  effusion  into  the  joint,  and  consequent  loosening 
of  knee  connections,  and  gradually  some  abnormal  flexion 
with  genu-valgoid  abduction  and  rotation  outwards  of  the 
tibia  took  place.  The  pressure  of  the  tibia  against  the  external 
condyle  led,  after  long-continued  use  of  the  limb  during  awk- 
ward modes  of  locomotion,  to  the  utmost  conceivable  destruc- 
tive internal  joint  changes,  the  reciprocal  wearing  away  of 
the  articulating  facets  of  the  tibia  until  the  head  of  this  bone 
approached  the  form  of  a  pestle,  and  erosion  and  disappear- 
ance of  the  external  condyle  of  the  femur,  through  which  a 
very  unworthy  species  of  new  joint  was  formed.  Doubtless 
muscular  action,  especially  that  of  the  bicej)s,  had  here 
been  an  important  factor  in  increasing  distortion,  as  it  is  in 
cases  of  ordinary  knock-knee ;  but  we  believe  it  may  be  re- 
garded as  certain  that  the  greater  part  of  the  mechanical 
changes,  represented  in  this  preparation,  was  due  to  statical 
influence, — the  act  of  walking  during  an  improper  bearing 
of  the  parts  upon  one  another  owing  to  loosening  of  their 
several  connections,  precisely  as  we  have  shown  distorted 
knee  to  arise  in  the  infant  and  adolescent  from  atonic 
relaxation  of  fibrous  tissues,  or  in  the  infant  from  rachitic 
softening  of  the  bony  structures. 


With  slight  atonic  or  idiopathic  knee  inversion  the  child 
in  walking  is  often  observed  to  turn  the  toes  in,  though  when 
the  feet  are  examined  it  is  found  that  each  foot  presents 


ANALOGY   WITH    IN- ANKLE    AND    BC0LI0SI8.  99 

what  the  nurse  calls  a  double-ankle,  i.  e.,  there  is  a  douljlo 
prominence  on  the  inside  of  the  ankle,  one  below  the  other, 
the  uppermost  being  the  internal  malleolus,  the  lower  the 
depressed  internal  margin  of  the  scaphoid.  Nevertheless 
such  feet  are  not  flat  (flat-foot,  platt-fuss)  and  a  well  developed 
arch  remains,  and  the  ankle  joint  remains  movable  in  all 
normal  directions,  even  to  excess,  owing  to  co-existing  want 
of  tone  in  the  ankle  ligaments  and  muscles,  a  state  of  things 
in  the  ankle  strictly  analogous  to  atonic  in-knee  in  its  early 
stage.  In  these  cases  if  the  laxity  does  not  subside  at  an 
early  age,  thorough  flat-foot,  i.  e.,  persistent  loss  of  arch, 
even  when  the  patient  is  seated,  with  limitation  of  ankle 
movement,  and  some  structural  adapted  shortening  of  the 
muscles  (tendons)  on  the  outside  of  the  ankle  (peronei  and 
extensor  communis  digitorum,  and,  in  extreme  cases,  tibi- 
alis ant.),  may  set  in.  The  nearer  the  approach  of  the  feet 
to  the  condition  of  thorough  flat-foot,  the  greater  is  the  ten-| 
dency  of  the  patient  to  persistent  eversion  of  the  toes. 
Thorough  flat-foot,  in  our  opinion,  more  often  accompanies 
rachitic  than  atonic  cases.     See  p.  7. 

Nature  or  gravity  works  in  the  lower  extremities  exactly 
as  in  the  spinal  column  affected  with  scoliosis,  or  twisting 
of  the  spine,  which,  as  we  have  already  said,  is  a  strictly 
analogous  distortion  to  in-knee,  occurring  in  distinct  forms, 
— the  atonic  and  the  rachitic*  Precisely  as  we  find  in 
scoliosis  one  or  more  successive  curves  established  by  the 
action  of  gravity  to  compensate  for  the  first  curve,  and  thus 
enable  the  individual  to  preserve  his  balance  and  maintain 
himself  in  abetter  poised  attitude,  so  we  see  in  the  successive 
deformities  of  the  lower  extremities  the  attempt  of  the  indi- 
vidual by  means  of  his  volition,  perhaps  automatically  exer- 

*  The  reader  who  desires  to  further  investigate  this  subject  is  re- 
commended to  consult  Alexander  Shaw's  article  on  "  Lateral  Curvature 
of  the  Spine,"  in  '  Holmes's  System  of  Surgery,'  2nd  edition  ;  and 
that  by  us  under  the  head  of  "  Scoliosis,"  in  the  3rd  edition. 


100  IN-KNEE    DISTORTION. 

cised,  to  graclually  eti'ect  by  a  succession  of  curves  or  zig- 
zags the  approximation  of  the  stand-points  of  the  body — 
the  feet,  so  as  to  bring  them  as  near  the  median  Hne  as  is 
Dl\gk\m  15.  required  for  security  and  convenience 

in  walking.  To  how  great  an  extent 
Nature  fails  in  her  efforts  is  shown  by 
the  progressive  augmentation  of  de- 
formity seen  in  the  worst  cases  of 
genu-valgum  (p.  45). 

It  is  in  young  subjects  in  whom  the 
distortion  is  far  from  attaining  the 
completeness  of  the  deformity,  shown 
at  p.  45,  that  the  successive  workings 
of  gravity  can  be  watched.  The  right 
limb,  fig.  4,  p.  6,  which  is  the  less  dis- 
torted, appears  more  under  the  con- 
trol of  the  will,  whilst  the  left  extremity 
appears  to  have  further  escaped  from 

Sclieinatic  arrangement  of 

curved    Umhs.      a  a  ^^^  influence.     The  right  knee  is  seen 

black  linen  intended  to  to  be  acting  as  a  better  buttress  to  its 

indicate  the  course  of  fellow,  whilst  the  right  foot  appears  to 

the  femurs;  b b,  ditto,  ^^  struggling  towards  the  median  line, 

ot  the  tibia ;  c  c,  ditto, 

re-entering  curve  of  the     ^nd    is   Uiverted,    whllst     its    felloW    IS 

lower  third  of  the  tibia    more  passivc,  and  is  everted. 
towards    the    median  The  annexed  diagram  is  intended 

me;    D D,  jeet  not-    ^^  represent  the  successive  angles  or 

mulUj  everted.  The  dot-  .  . 

,  ,  ,.  ,   ,,      curves  formed  m  the  course  of  a  lower 

ted   lines    around    tlie 

left  schematic  lines  re-  extremity  through  the  action  of  gravity, 
pre-<ent  the  contour  of  and  the  efforts  of  the  individual  mani- 
the  supposed  deformed    ^^^^^^^  ^^^   muscular  action  and  mode 

limb  covered  wtth  Jiesh.         .  •        jt 

01  standnig  to  regam  the  perpen- 
dicular. We  see  many  young  children,  usuall}^  rickety,  in 
whom,  in  addition  to  moderate  double  in-knee,  we  find  the 
itibise  fairly  straight  in  their  upper  halves  or  two-thirds,  the 
lowest  portions,  however,  being  deflected  inwards  towards 


MECHANISM    OF    CURVES    IN    THE    LOWER    LIMBS.  101 

the  perpendicular  line.  We  have  also  seen  young  non- 
rachitic subjects  of  in-knee  presenting  similar  curves  to 
that  represented  in  the  diagram,  so  that,  as  already  stated, 
mere  curvature  of  bone,  taken  alone,  is  not  a  certain  sign 
of  rachitis.  We  have  before  mentioned  the  occurrence  of 
curvature  of  bones,  in  addition  to  yielding  inwards  of  knee, 
from  atonic  causes. 

We  have  also  spoken  of  curvature  of  bone  from  organic 
want  of  nutrition,  and  atrophy  of  bone  in  paralytic  cases. 
Mr.  Hutchinson,  at  the  Pathological  Society's  Discussion, 
1880,  remarked  that  he  had  seen  bone  cm-vatures  due  to 
syphilis.  Considering  the  frequent  intervention  of  this 
disease  in  the  medical  history  of  childhood,  the  fact  of 
syphilitic  bone  curvatures  appeared  to  be  a  disturbing  ele- 
ment in  the  pathology  of  bone  curvature,  and  especially  in 
relation  to  rachitic  curvatures.  It  has  been  satisfactory  to 
find  that  when  a  member  of  the  recent  International  Medical 
Congress  (see  Trans.,  1881)  endeavoured  to  connect  all 
rachitis  with  syphilis,  not  one  speaker  was  found  to  endorse 
this  opinion. 

It  may  be  remembered  that  the  writers  on  rachitis, 
during  the  middle  of  the  last  century,  described  seven  or 
eight  forms  of  this  disease,  one  of  which  was  the  syphilitic 
form,  which  has  long  been  abolished  by  subsequent  writers. ' 
In  fact  a  better  study  of  this  disease  has,  as  in  so  many 
other  diseases,  simplified  the  knowledge  of  it. 

To  return  for  a  moment  to  the  theory  here  introduced 
to  account  by  mechanical  agency  for  the  particular  curves 
manifested  in  bones  weakened  by  rachitis,  admitting  at  the 
same  time  the  influence  in  production  exercised  by  the 
more  bulky  mass  of  muscles,  we  direct  attention  to  a 
common  form  of  rachitic  curvature  (fig.  39).  We  may  pre- 
mise that  we  do  not  remember  having  seen  a  rachitic 
curved  femur  (not  due  to  former  fracture)  in  which  rachitic 
curvature  of  leg  bones  did  not  co-exist.     Now  let  the  reader 


102 


IN-KNEE    DISTORTION. 


observe  the  thigh  curvature  forwards  and  outwards,  the  leg 
curvature  forwards  and  inwards,  and  the  ankle  twist,  owing 
to  which  the  point  of  the  foot  is  directed  outwardly,  the 
weight  being  mainly  borne  by  the  heel  and  great  toe.  The 
student  will  better  understand  the  production  of  out-knee 

Fig.  3'.». 


A  common  form  of  rickety  curvature  of  loiver  extremities  :  curved  femur, 
out-knee,  in-ankle,  everted  foot  [talipes  valgus),  all  more  marked  {in  this 
instance)  on  the  right  side;  [e)  the  outer  margin  of  foot  almost  raised  from  the 
ground,  the  principal  weight  being  borne  through  the  great  toe.  From  Little, 
'  On  Deformities.'' 

(genu-varum)  after  comparing  fig.  39  with  fig.  18,  and  note 
the  succession  of  curved  zigzags  which,  in  the  interest  of 
locomotion,  gravity  leads  the  limb  to  take.  In  figure  40 
the  right  foot  has  an  unusnal  inward  inclination,  instead 
of  an  outward  one,  probably  because  the  rickety  child  in 
question  principally  effected  locomotion  with  this  limb  tucked 
beneath  the  nates,  using  the  left  limb  as  a  paddle  against 
the  floor. 


ACCOMMODATIVE    CURVES    IN    SPINE    AND    LIMBS. 


103 


Fig.  40. 


In  illustration  of  the  mode  of  production  of  curvature  of 
thigh  and  leg  bones  we  append  (fig.  41,  p.  104)  the  drawing  of 
an  adolescent,  presenting  the  results  of  infantile  hemiphlegia, 
— attenuation  of  the  left  side  and  extremities  especial 
wasting  of  the  left  thigh  and  leg,  com- 
parative robustness  of  the  right  arm 
and  right  side  of  the  trunk,  greater 
stoutness  and  length  of  the  right 
thigh,  greater  length  of  right  leg, 
right  foot  flat.  Eight  out-knee  and 
outward  curvature  of  right  leg  bones 
exist  as  the  consequence  of  its  dispro- 
portionate length,  owing  to  accom- 
modative, structural  shortening, 
compensating  in  some  degree  for 
the  diminished  length  of  the  oppo- 
site limb.  The  spinal  curvatures 
in  the  drawing  were  temporary  only, 
for  they  entirely  disappeared  when 
the  left  foot  was  raised  from  the  ground  by  the  interposition  of 
a  book  of  sufficient  thickness  to  compensate  for  the  shorten- 
ing. The  drawing  further  shows  the  completeness  with 
which  the  successive  spinal  curvatures,  in  a  manner  and 
with  a  purpose  analogous  to  that  in  which  gravity  operates 
in  producing  curvatures  of  bones  and  yielding  of  the  joints  in 
the  lower  extremities,  enables  the  head  to  be  carried  in  the 
erect  position,  and  an  upright  position  of  the  frame,  as  a 
whole,  is  maintained.  But  the  greatest  interest  here  afforded 
by  this  case  is  that  the  outward  curvature  of  the  right  lower 
limb  is  simply  accommodative,  and  not  due  to  rachitic 
softening.  There  was  no  where  to  be  found  in  the  economy 
any  indication  of  previous  rachitis.  It  may  be  said,  there- 
fore, that  curvature  may  occur  in  sound  bones  through 
shortening  accommodative  to  short  bones  in  the  opposite 
limb,  in  the  bones  of  paralytic  limbs  through  their  organic 


Rachitic  out-knee  curvatures 
of  long  bones  in  a  young 
child.  From  Little,  '  On 
Deformities.'' 


104 


IN-KNEE    DISTORTION. 


Fig.  41. 


nutrition  being  deficient,  in  the  bones  of  persons  affected 

with  atony  of  fibrous  and  osseous 
structures  without  signs  of  rickets, 
and,  above  all  and  most  commonly, 
in  distinctly  rachitic  subjects. 

When  we  are  considering  the 
action  of  the  superincumbent  weight 
upon  the  limbs  which  are  weakened 
by  loss  of  tone  of  the  fibrous  or 
osseous  structures,  we  should  re- 
member that  just  as  either  the 
femur  or  the  tibia,  when  softened, 
is  disposed  to  yield  rather  towards 
the  middle  of  its  length  than  in  any 
other  position,*  (see  fig.  4'2),  so  the 
part  of  the  lower  extremity  which 
will  be  most  disj)Osed  to  yield  to 
gravity  will  be  that  part  which  is 
nearest  to  the  middle  of  its  entire 
length,  viz.,  the  knee ;  thus  in-knee 
will  be  engendered  under  the  other 
favouring  circumstances  which  have 
already  been  considered — the  knee 
being  in  fact  nearly  midway  be- 
tween the  summit  of  the  head  of  the 
femur  and  the  sole  of  the  foot. 
As  an  aid  to  diagnosis  of  rickets, 
curvature  onhj,  due  to  in-  gii-  "W.  Jenner  (Keport  of  Discuss. 

faniUe   hemipiaegia.      From    at  Patholog.  SoC,  1880)  dwelt  upon 

the  well-known  form  of  the  skull, 
especially  the  depression  over  the  suture  between  the  two 
frontal  eminences.  This  particular  sign  of  rickets,  which  is 
a  positive  one,  is  like  any  other  sign,  not  invariably  present, 
or  not  always  present  in  so  marked  a  degree.     Quite  as 

■■'-  '  Traite  du  rakitis,'  par  Levacher  de  la  Feutrie,  Paris,  1772,  x^.  84. 


Accommodative  curve  of  right 
lower  extremity,  and  appa- 
rent,  hut   temporary,   spinal. 


SIGNS    OF   RICKETS    IN    THE    CRANIUM. 


105 


characteristic  of  rickets  is  the  undue  projection  and  acute- 
ness  of  those  eminences,  for  they  arc  frequently  out  of  pro- 
portion to  the  depth  of  the  suture.  As  already  stated  we 
should   depend  upon  more  than  a  single  sign.     Delay  in 


Fig.  42. 


One  of  the  commonest  forms  of  rickety  curvature,  to  illustrate  the  tendency  to 
yielding  toioards  the  middle  of  the  shaft. 


closure  of  the  fontanelles  is  one  of  the  signs  of  rickets,  just 
as  in  another  manner  it  becomes  the  sign  of  another 
diseased  state,  hydrocephalus,  through  the  individual  bones 
having  been  mechanically  kept  asunder  by  the  effused  intra- 
cranial fluid.  From  an  early  period  a  connected  disease 
between  rickets  and  hydrocephalus  has  been  believed  to 
exist, — hydro-rachitis.  Further  study  of  rachitis,  hydro- 
cephalus, and  hydro-rachitis  is  required  to  determine  whether 
this  is  a  separate  form  of  disease,  or  whether  it  merely 
represents  a  simultaneous  combination  of  symptoms  of  the 
same  disease. 


106  IN-KNEE    DISTORTION. 

The  recent  discussions  at  the  Pathological  Society  and 
at  the  International  Medical  Congress  on  the  diagnosis  of 
rickets  from  other  diseases,  and  the  pains  we  have  here 
taken  to  enumerate  the  clinical  and  other  distinctions 
between  them,  would  justify  the  idea  that,  after  so  long 
observation  as  that  to  which  rachitis  has  been  subjected 
during  two  centuries  and  a  half,  it  is  still  difficult  for  the 
physician  to  discriminate  it.  We  believe  that  in  having 
eliminated  from  rickets  the  greater  number  of  in-knee  and 
in-  or  weak-ankle  cases,  just  as  Guerin  and  Alexander  Shaw 
a  generation  ago  showed  that  scoliosis  is  commonly  not  a 
rachitic  affection,  we  shall  have  done  good  service  in  the 
way  of  diagnosis  and  treatment. 

Amongst  the  well-marked  symptoms  of  rickets  may  be 
mentioned  the  clefts  or  deep  creases  in  the  integuments  in 
the  less  severe  cases,  as  at  the  upper  and  inner  part  of  the 
thigh,  even  in  fat  children,  whicli  are  signs  of  hent  hones 
beneath.  In  the  later  stages  greater  hairiness  of  the  general 
surface  is  sometimes  perceptible.  It  occm-s  mainly  on  the 
back,  arms  and  sides  of  the  face.*  The  late  production  of 
teeth,  and  their  incomplete  character  as  regards  both  enamel 
and  dentine,  with  premature  shedding,  almost  forms  a  patho- 
gnomonic sign.  We  may  often  in  the  later  age  of  rickety  sub- 
jects note  in  the  succession  of  imperfect  rings  of  enamel,  and 
of  discoloured  dentine  in  the  second  set  of  teeth,  the  phases 
of  temporary  alternate  amelioration  and  deterioration  of 
the  former  constitutional  state  of  the  child. t  The  physio- 
pathological  relation  between  the  symptom  of  unusual 
hairiness  and  that  of  defective  teeth,  if  any,  has  not  been 
determined.  We  venture  the  following  remarks  for  further 
consideration  as  to  the  possible  relation  of  undue  hairiness 
to  defective  solidification  of  bones  in  rickets.  It  is  known 
that  the  primary  mould  of  the  bone  in  the  embryo  is  a 

*  Aitken:  '  Science  and  Practice  of  Medicine,'  18G6. 
•j-  See  Hutchinson  :  Pathol.  Transact.,  1880. 


UNDUE    HAIRINESS    IN    RICKETS.  107 

tolerably  firm  one,  composed  of  some  form  of  the  gelatinous 
group  of  animal  substances,  in  which  first  cartilaginous 
cells,  and  later  on  bone  particles,  are  developed,  as  if  poured 
in  for  the  purpose  of  successive  degrees  of  hardening.  We 
know  also  that  by  long  soaking,  in  an  acid  solution,  a 
healthy  bone  removed  from  the  body,  the  mineral  matters 
can  be  removed,  and  the  bone  be  restored  to  a  quasi-foetal 
condition.  The  normally  firm  bone  is  thereby  shown  to 
consist  essentially  of  a  gelatinous  element  and  a  bone 
element,  plus  blood,  blood  vessels  and  nerve  elements.  If 
we  regard  the  rachitic  infant's  condition  as  one  of  abnormal' 
nutrition,  whether  hereditarily  predisposed  (p.  83)  or  ac- 
quired, and  that  tooth  and  bone  belong  to  the  same  chemical 
category,  may  not  the  bone  phenomena  of  rachitis,  owing  to 
abnormal  nutrition,  represent  a  quasi  more  or  less  complete 
starvation  of  the  bones,  and  misappropriation  of  the  primary 
essential  building  up  materials,  viz.,  of  the  gelatine  com- 
pound constituting  the  mould  of  the  bone,  and  of  the  earthy 
more  solidifying  material  ?  The  exudation  of  the  sanguineous 
jelly  found  to  exist  in  the  interior  and  on  the  surfaces  of  the 
most  affected  portions  may  excite  absorption  from  the  bones 
of  the  gelatine  case  and  contained  earthy  materials.  If 
this  be  so,  may  not  the  unemployed  gelatine  material  appear 
in  the  shape  of  keratin  in,  and  give  rise  to,  the  super- 
abundant hair-growth,  and  the  earthy  matters  appear  as 
phosphatic  deposits  in  the  infant's  urine?* 

*  Having  stated  (p.  31)  that  Jules  Guerin  had  not  distinguished 
non-rachitic  in-knee  from  the  rachitic  form,  and  having  corrected  that 
error  (p.  33)  by  showing  that,  in  the  very  recently  published  'Trans- 
actions of  the  International  Congress  of  1881,'  this  distinguished 
physician  had  described  four  forms,  we  owed  it  to  him  to  examine  his 
intermediate  writings  on  distortions,  and  to  note  that  in  his  '  Eapport 
sur  les  traitements  orthopediques,'  1848,  p.  98,  speaking  of  "  deviation 
du  genou  en  dedans,"  he  mentions  that  out  of  five  cases  two  were  not 
rickety. 


ON    TREATMENT. 


The  experience  acquired,  and  published  by  us  a  gene- 
ration ago,  showed  the  treatment  of  in-knee  in  infants, 
children,  and  adolescents  to  be  one  of  the  most  successful 
offices  in  which  the  practitioner  in  deformities  could  be  en- 
gaged. We  can  affirm  that  of  this  distortion  amongst  cases 
at  all  ages,  in  all  classes  of  society,  in  private  practice,  and 
in  hospitals  general  and  special,  we  have  only  met  with  two 
cases  which  had  been  successfully  rebellious  to  restoration,* 
as  far  as  the  actual  knee  inversion  was  concerned. 

It  will  be  noticed  farther  on  how  large  a  number  of  pre- 
viously reputed  irremediable  cases  of  in-knee  and  rickety 

*  One  of  tliese,  a  nou-racliitic  case  in  the  right  knee  of  a  young 
woman,  which  had  been  perfectly  straightened,  but  which  remained 
straight  only  so  long  as  mechanical  apparatus  was  used.  When  she 
stood  unsupported  the  knee  yielded  inwards,  the  joint  was  loose  and 
"wobbly."  Although  the  limb  could  be  straightened  it  was  obvious 
that  the  hard  and  soft  structures  composing  and  surrounding  the 
articulation  had  not  adapted  themselves  to  their  restored  proper  rela- 
tions (p.  29).  In  short,  the  I'ecovery  of  tone  by  the  soft  structures  and 
interstitial  absorption  of  excess  of  bony  tissue  in  one  part,  and  inter- 
stitial deposit  where  wanted  in  another  part,  as  had  invariably  been 
observed  by  us,  had  not  taken  place.  We  were  informed  that  in  this 
supposed  case  of  inveterate  in-knee  that  the  i^atient,  if  not  also  the 
medical  attendant,  had  "  played  fast  and  loose"  with  it.  We  only  saw 
this  case  once  in  medical  consultation.  The  second  one,  rachitic,  aged 
thirteen,  one  leg  presenting  in-knee,  the  other  out-knee,  with  consider- 
able curvature  of  thigh  and  leg  bones,  had  worn  instruments  for  years. 
The  parent  and  instrument  maker  stated  that  the  distortion  had  much 
diminished  under  instrumental  treatment.  The  instruments  were  con- 
tinued two  years  longer;  the  knee  joints  were  straightened,  but  were 
loose,  and  relapsed  on  removal  of  support.  Osteotomy  was  proposed 
for  the  curvatures,  but  declined. 


SUCCESS    OF    TREATMENT    BY    GENTLE    MEANS.  109 

curvatures  have,  since  the  introduction  of  osteotomy,  turned 
up  from  pubHc  cripples'  homes,  union-houses,  and  the  remote 
abodes  of  the  poorest  classes  in  large  cities.  If  the  know- 
ledge of  the  existence  of  the  means  of  prevention  of  distor- 
tion during  early  childhood  had  permeated  the  profession  at 
large, — if  the  example  afforded  by  the  establishment  of  ortho- 
paedic hospitals,  and  subsequently  of  special  departments  for 
orthopaedic  practice  in  the  general  hospitals  in  the  metro- 
polis, had  been  largely  followed  elsewhere, — such  large  arrears 
of  humanity  would  not  have  been  left  to  the  present  gene- 
ration of  surgeons  to  clear  off. 

Advantage  to  the  completion  of  the  knowledge  of  in-knee, 
as  of  other  morbid  conditions,  and  their  treatment,  arises 
when  observers  approach  the  subject  from  a  different  point 
of  view,  and  at  different  periods  of  time.  Of  late  years 
severe  genu-valgum  has  presented  itself  to  us  less  frequently 
than  a  generation  ago,  presumably  because  in  this  large 
centre,  London,  the  diffusion  of  successful  methods  of  treat- 
ing the  earlier  stages,  as  in  infancy  and  childhood,  has  re- 
duced the  number  of  severe  knock-knees  in  adolescents  and 
adults  at  the  present  day.  Judging  from  the  experience 
of  Professor  Macewen,  of  Glasgow,  an  unusually  large 
number  of  uncured  adolescent  and  adult  cases  was  to  be 
found  in  that  neighbourhood  until  he  brought  his  mind  and 
hands  to  the  relief  of  the  mass  of  lameness,  deformity,  and 
suffering.  It  is  impossible  to  avoid  the  conclusion  that 
either  poverty  of  the  parents  of  so  many  sufferers,  or 
ignorance  that  means  of  prevention  and  cure  were  avail- 
able, or  other  unsuspected  cause,  can  account  for  so  many 
instances  of  this  particular  complaint  being  found  by  him. 

The  treatment  of  infantile  cases,  whatever  their  origin, 
consists  of  two  parts, — the  constitutional,  that  by  which  it 
is  sought  to  ameliorate  the  general  health,  removing  at  the 
same  time  the  affections  of  internal  organs,  which  are  apt 
to  be  associated  with  constitutional  debility  at  this  suscep- 


110  IN-KNEE    DISTORTION. 

tible  period  of  life,  and  the  mechanical  means  employed  to 
support  ■sveak,  and  straighten  distorted,  joints. 

All  infantile  cases  of  in-knee,  whether  rachitic  or  non- 
rachitic, may,  as  regards  mechanical  treatment,  be  classed 
together,  and  treated  upon  the  same  principles  and  by  the 
same  means,  modified  in  particular  cases  according  to  the 
degree  and  variety  of  the  distortion.  When  treating  of  the 
causes  and  nature  of  in-knee  (p.  67),  and  speaking  of  the 
origin  from  neglect  of  dietetic  and  hygienic  influences,  we 
have  foreshadowed  our  opinion  of  the  constitutional  remedies 
necessar}^  to  check  the  progress  of  distortion,  and  shall, 
therefore,  leave  this  subject  to  the  individual  judgment  and 
experience  of  every  physician.  We  will  permit  ourselves  one 
comprehensive  remark  only,  that  as  soon  as  infantile  debi- 
lity, which  is  apt  to  precede  deformity,  shows  itself,  the 
child  manifesting  less  firmness  of  Hesh,  weakness  of  loins, 
consequent  inability  to  sit  up,  delayed  appearance  of  teeth, 
or  when  actual  knee  weakness  and  morbid  tendency  to  in- 
version of  knee  appears,  the  diet  of  the  hand-fed  fast-growing 
infant  should  be  changed ;  water  should  be  discarded  for 
milk,  or  the  nursing  mother's  probable  insufficiency  of 
supply  and  quality  be  exchanged  for  a  more  robust  diet, — 
farinaceous  and  vegetable  food  should  be  introduced ;  meat 
in  small  quantities,  suitably  prepared,  be  allowed;  a  dry 
food,  as  it  were,  be  substituted  for  a  too  watery  one.  In 
mere  atonic  laxity  and  distortion  we  have  little  faith  in 
special  chemical  foods  or  in  drugs  to  meet  the  child's 
requirements,  except  when  other  symptoms  of  disordered 
health  are  present.  The  same  remark  applies  to  the  ex- 
ternal use  of  imported  or  artificial  sea  icater,  and  other 
external  applications.  Such  expedients  tend  to  divert  atten- 
tion from  the  more  immediately  necessary  mechanical  means 
to  avert  or  remedy  incipient  distortion. 

The  constitutional  treatment  of  the  rachitic  infant,  also, 
should  be  considered  on  the  same  principles  as  the  case 


CONSTITUTIONAL    TREATMENT.  Ill 

arising  simply  from  unsuitable  diet.  If  the  mother  be  of 
rachitic  family,  a  wet-nurse  of  a  sounder  constitution  should 
be  preferred  for  the  child.  This  is  not  the  place  to  enter  on 
the  full  consideration  of  the  nature  and  treatment  of  the 
extensive  disease  of  the  system  at  large  understood  by 
rachitis.  We  have  remarked  (p.  83)  that  in  our  opinion 
this  disease  is  as  special  a  disease  as  cancer  or  tubercle, 
and  other  diseases  which  are  believed  to  arise  from  special 
sources.  It  appears,  for  the  most  part,  in  our  opinion, 
hereditary,  if  not  always  so.  If  it  does  not  destroy  life  by 
urgent  rachitic  complications,  hydrocephalus,  bronchitis,' 
convulsions,  disorders  of  the  chylopoietic  viscera,  it  follows 
as  regards  its  manifestations  in  the  osseous  structures  two 
distinct  stages,  those  of  softening  and  of  subsequent  undue 
hardening  of  them ;  and  as  regards  the  teeth  two  stages  of 
growth,  the  first  in  which  there  is  little  or  no  ordinary  dentine 
or  enamel  deposited,  and  a  later  stage,  as  in  the  second  set, 
in  which  increase  of  bone  tissue  and  enamel  takes  place. 

One  thing  appears  to  be  as  certain  of  rachitis  as  of  the 
special  diseases  mentioned,  that  medicine  can  neither  arrest 
nor  prolong  the  time  which,  as  regards  the  bones  and  teeth, 
is  occupied  in  the  above-mentioned  stages.  We  continually 
see  children  affected  with  rachitic  distortions  who  have 
traversed  the  disorder  of  rickets  untended  by  physicians, 
and  to  whom  no  remedies  have  been  applied,  who  have 
reached  the  stage  of  eburnation  and  cessation  of  the  rachitis 
in  the  system  at  the  same  age  as  those  who  had  been 
subjected  to  medical  treatment.  Except  as  to  the  dis- 
tortions and  intercurrent  rachitic  internal  complications,  it 
may  be  said  that  the  disease  runs  its  course  and  subsides 
at  a  fixed  period  inherent  to  it.* 

*  Wunclerlicli,  C.  A. :  '  Handbuch  der  Pathologie  imd  Tlierapie,' 
vol.  ii.,  p.  939.  Jenner :  '  Med.  Times  and  Gazette,'  vol.  i.,  1860. 
Holmes  :  '  System  of  Surgery,'  vol.  iv.,  p.  843.  Atliol.  A.  Jolmson  : 
ditto,  vol.  iii.,  p.  750. 


112  IN-KNEE    DISTORTION. 

Moreover,  as  stated  (p.  78),  rachitis  never  occurs  after 
infantile  age,  and  never  recurs  during  pubert_y,  adolescent 
or  adult  age  in  those  who  were  seized  with  it  in  infancy. 
Elsewhere  we  have  shown  that  those  writers  on  this  dis- 
tortion, who  have  asserted  that  rickets  originates  during 
adolescence  or  adult  age,  have  so  stated  because  of  their 
propossessions  that  this  distortion  only  occurs  in  rachitic 
subjects.  Notwithstanding  the  views  here  expressed  as  to 
the  nature  and  course  of  rachitis,  and  the  dependence  of  one 
form  of  knee  inversion  upon  it,  we  do  not  advise  relinquish- 
ment of  the  use  of  alkaline  earths  when,  in  rachitis,  the 
condition  of  the  gastric  secretion  denotes  undue  acidity,  or 
of  steel  wine — cod  liver  oil,  sometimes  with  small  doses  of 
orange  wine,  when  mal- assimilation  indicates  inpending 
marasmus. 

Until  statistics  shall  have  enabled  others  to  confirm  the 
views  here  announced  it  would  be  wrong  to  throw  away  a 
possible  chance  of  benefit  to  rachitic  subjects,  and  not  to 
employ  articles  of  at  least  a  neutral,  if  not  a  sustaining, 
quality.  We  have  had  children  brought  to  us  who  have 
taken,  with  the  decidedly  mischievous  effect  of  burdening 
the  alimentary  canal,  cretaceous,  phosphatic  and  alkaline 
compounds,  and  advertised  chemical  foods,  continuously  for 
three  years,  owing  to  the  belief  that  such  things  are  really 
nutritious,  just  as  we  have  had  a  patient  suffering  from  a 
neurosis  bring  with  her  a  prescription  containing  strychnine, 
which  she  had  taken  continuously  for  twelve  years.* 

When  treating  rachitic  cases,  in  which  we  have  reason 
to  believe  that  either  of  the  parents  is  of  rachitic  descent, 
and  that  the  child  is  old  enough  to  be,  or  must  be,  hand- 
fed,  we  should  remember,  before  prescribing  drugs,  that  milk, 
oat-meal,  wheat-flour,  mutton    and  beef  contain  a  large 

*  See  Bouvier  on  the  incorrectly  asserted  sovereign  virtues  of  ol. 
inorrliuie  in  rickets,  and  on  what  he  calls  the  "  dephosphiation  of  the 
blood,"  ojj.  cit. 


TEEATMENT    BY    MECHANICAL    APPARATUS.  113 

quantity  of  earthy  phosphates  in  an  easily  assimilable  form 
to  supply  the  place  of  any  possible  hereditary  cleficiency  of 
such  ingredients  in  the  blood. 

The  surgical  treatment  may  be  divided  into  two  parts  : 
that  which  consists  in  manipulations  by  a  competent 
attendant,  or  in  the  suitable  application  of  splints  and 
other  mechanical  contrivances  for  the  purpose  of  bringing 
the  knee  structures  by  gentle  means  into  a  proper  relation 
to  each  other,  and  effacing  the  in-knee  temporarily  and 
permanently  (see  p.  51) ;  and  that  which  consists  of  more 
abrupt  means,  such  as  have  been  used  in  severe  cases, — 
tenotomy,  forcibly  straightening  under  anassthesia,  and 
osteotomy. 

In  every  mode  of  treatment  the  surgeon  has  to  bear  in 
mind  that  the  principle  involved  in  successful  treatment  is 
to  place  and  retain  the  knee  in  such  a  position  that  the 
articular  surfaces  of  the  external  side  of  the  joint  be  re- 
lieved from  undue  pressure,  in  order  that  they,  when  thus 
relieved,  may  gradually  return  to  the  normal  state  of  growth, 
shape,  and  size,  a  tendency  to  which,  under  favourable  cir- 
cumstances, is  always  apparent  in  the  economy. 

C.  Hueter  proposes  to  effect  this  object  by  bending  the 
knee  to  a  right  angle,  and  fixing  it  in  that  position  by 
means  of  bandages,  thus  effectually  preventing  the  patient 
from  using  the  limb.  He  speaks  contentedly  of  this  method. 
He  omits  to  state  how  long  he  was  obliged  to  continue  it. 
It  is  obvious  that  it  is  not  applicable  when  both  limbs  are 
affected,  unless  the  patient  is  to  be  confined  to  the  couch  or 
perambulator.  If  applicable  to  a  single  limb,  and  the 
patient  be  allowed  to  move  about,  with  the  help  of  a  crutch 
or  stick,  it  is  objectionable,  because  of  the  tendency  which 
then  would  arise  to  undue  use  of  the  other  limb,  which  pro- 
bably will  already  have  some  tendency  to  the  same  disease. 
The  plan  is  novel  and  interesting  by  its  showing  a  distinct 
recognition  of  the  correct  principle  of  treatment,  the  relief 

Q 


114  IN-KNEE    DISTORTION. 

of  certain  Imee  structures  from  undue  pressure,  and  the 
encouragement  of  them  to  renewed  growth.  We  have  re- 
sorted to  the  plaster  of  Paris,  starch,  or  gum-handage.  This 
plan  is  applicahle  in  very  slight  cases,  where  the  surgeon 
contemplates  employing  it  for  only  two  or  three  weeks.  All 
familiar  with  the  treatment  of  distortions  are  aware  of  the 
evil  of  retaining  any  joint  many  days  at  a  time  in  an  extended 
position,  compressed  throughout  in  a  close-fitting  circular 
direction,  especially  during  infancy,  when  growth  is  very 
rapid.  We  have  seen  a  knee  permanently  lessened  in  size 
compared  with  its  fellow  after  tight  bandaging.  It  is  true 
that  the  previously  deficient  external  portions  of  the  femur 
and  tibia  may  be  released  from  pressure,  and  thus  be  en- 
couraged to  grow;  but  during  a  long-continued  fixed  ex- 
tended position  of  the  knee  joint,  the  normal  shape  of  the 
articular  eminences  is  likely  to  be  more  or  less  changed, 
owing  to  the  prolonged  entire  repose  in  one  position ;  and 
we  know  that  partial  ankylosis  is  thus  easily  produced. 
Another  great  objection  is  that  a  return  to  movement  of  the 
joint,  after  the  plaster  of  Paris  treatment,  is  a  painful  pro- 
ceeding. . 

The  first  step  to  be  taken  in  the  treatment  of  infantile 
cases  is  to  teach  the  parent,  "  rubber"  or  nurse  the  proper 
manner  in  which  the  part  can  be  manipulated  with  prompt 
unmistakable  benefit.  It  has  been  stated  (p.  27)  that  in  the 
young  an  abnormal  lateral  mobility  of  the  knee  (wobbling) 
is  a  marked  symptom  of  in-knee.  If  the  recumbent  child's 
legs  appear  to  be  abducted,  each  to  about  50°  or  60°,  each 
knee  can  successively  be  brought  by  the  attendant  from 
the  position,  a,  h,  nearly  to  a — d  (see  diagram  a,  p. 
27),  by  the  most  gentle  painless  pressure.  The  degree 
of  temporary  restoration  thus  effected,  is  the  measure 
of  the  degree  of  improper  movement  of  the  knee.  It  is 
not  necessary  that  the  parent  or  rubber  should  at  the  first 
attempt  entirely  overcome  the  inward  bulge  of  the  knee ; 


TREATMENT    BY   MANIPULATION. 


115 


after  every  clay's  attempts  this  will  become  easier.  It  has 
been  mentioned  (p.  56)  that  if  the  knee  be  bent  the  ^enu- 
valgum  disappears  ;  for  the  same  reason  during  manipula- 
tions it  is  necessary  that  the  manipulator  should  keep  the 
limb  extended,  but  not  hyper-extended.  The  nurse  or  rubber 
should  not  be  too  hasty  or  forward  with  her  measures  ;  she 
should  be  gentle,  capable  of  simultaneously  amusing  the 
child  or  withdrawing  its  attention  from  her  doings.  If  the 
child  should  resist,  which  may  follow  too  tight  grasping  of 
the  limb,  or  be  impatient  and  withdraw  the  limb,  he  bends 
the  knee  or  rotates  the  thigh,  so  as  to  defeat  the  rubber's 
intention  to  straighten  it :  tact  on  the  part  of  the  nurse  or 
rubber  soon  overcomes  any  difficulty. 

In  figs.  43  and  44  are  represented  the  manner  in  which 
we  have  taught  parents  and  rubbers  to  economise  time  and 


Fig.  43. 


Fig.  44. 


trouble  by  straightening  the  two  limbs  at  the  same  time.  In 
both  figures  a  disc  of  cork,  ^  or  |  inch  thick,  according  to 
the  age  of  the  patient,  is  represented,  which  is  covered  with 


116  IN-KNEE    DISTORTION. 

a  layer  of  cotton-wool  and  sewn  up  in  silk.  The  disc  serves 
as  a  .fulcrum  between  both  internal  condyles,  whilst  each 
leg  being  grasped  by  one  hand  of  the  rubber  serves  as  a 
lever.  By  the  rubl)er  gradually  bringing  her  two  hands 
gently  together  both  in -knees  are  temporarily  converted 
into  straight  knees,  and  by  repetition  of  the  process  after  a 
few  days,  in  the  young  child,  each  limb  could  he  carried 
beyond  the  straight  line,  even  to  the  opposite  condition  of 
genu-extrorsum.  The  "knack"  of  doing  this  valuable 
movement  of  temporary  restoration  is  soon  acquired.  It 
should  be  pursued  with  gentleness,  as  we  have  said,  the 
nurse  watchfully  noting  the  temper  and  disposition  of  the 
child,  so  as  to  pause  when  the  child  appears  disquieted. 
The  process  may  be  repeated  several  times  daily,  each 
"sitting"  being  at  three  or  four  hours  interval.  If  the 
child  is  old  enough  to  follow  directions,  say  over  three  years, 
it  may  be  instructed  to  stand  erect  against  a  wall,  with  the 
padded  disc  between  the  condyles,  and  the  inner  margins  of 
the  feet  touching,  the  limbs  temporarily  verging  to  genu- 
extrorsum.  Many  slight  degrees  of  in-knee,  brought  for 
consultation  in  the  earliest  stage  by  parents  on  account  of 
the  child  being  accustomed  to  turn  the  toes  in,  or  because 
the  child  has  "double-ankles,"  "flat-foot,"  or  spurious 
talipes-valgus,  are  entirelj^  cured  by  the  parents  who  have 
been  taught  this  mode  of  manipulation,  without  the  em- 
ployment of  splints,  moderate  exercise  of  limbs  being 
permitted. 
f  A  most  simple  mechanical  aid,  from  which  we  have  de- 
rived benefit  in  the  earliest  stage  of  atonic,  strumous,  or 
rheumatic  in-knee,  consists  in  placing  a  soft  cushion  |  inch 
thick,  large  enough  to  cover  the  whole  of  the  inside  of  the 
internal  condyle,  or  condyles,  and  teaching  the  parent  or 
nurse  to  secure  it,  in  its  proper  position,  by  a  roller 
bandage.  The  standing  exercise,  mentioned  above,  should 
be  practised  as  there  described. 


TREATMENT    BY    SPLINTS. 


117 


When  the  in-knee  is  somewhat  more  advanced,  support 
from  one  or  tAvo  splints  during  a  considerable  portion  of 
each  twentj^-four  hours  may  he  needed.  It  should  be 
emphatically  borne  in  mind  that  in  treatment  by  instru- 
mental appliances  it  is  necessary  to  prevent  voluntary 
bending  of  the  knee  during  their  use.  The  value  of  this 
advice  admits  of  no  question.  Like  Hueter's  plan  it  effects 
one  important  object,  that  of  freeing  the  external  side  of 
the  joint  from  pressure. 

The  simplest,  least  expensive  and  least  burdensome  of 
appliances  are  light  ordinary  wooden  splints,  properly 
padded,  secured  in  position  by  ordinary  soft,  somewhat 
yielding,  roller  bandages.  The  first  of  these  splints,  six  to 
eight  inches  long,  padded  along  its  whole  length,  for  a  child 
under  two  years,  requires  to  be  lightly  secured  behind  the 
knee  to  prevent  bending  by  means  of  a  roller  bandage. 
If  the  distortion  be  so  considerable  that  it  can- 
not be  sufficiently  diminished  by  such  gentle 
pressure  of  the  surgeon's  hand  as  will  enable 
him  to  apply  satisfactorily  an  ordinary  straight 
splint,  as  above  described,  he  will  find  ad- 
vantage in  the  substitution  of  a  light  metal 
padded  splint,  jointed  in  the  horizontal  direc- 
tion, represented  in  fig.  45.  Such  a  splint, 
lightly  secured  by  a  roller  bandage,  will  re- 
main evenly  applied  to  the  back  of  the  knee, 
however  great  may  be  the  degree  of  genu- 
valgum.  Afterwards  a  second  splint,  reaching 
from  below  the  trochanter  to  the  outer  ankle,  padded 
only  for  a  distance  of  two  to  three  inches  at  the  two  extre- 
mities, should  be  bandaged  along  the  outside  of  the  limb. 
See  fig.  46.  This  second  splint  when  properly  applied,  so 
that  the  outer  hollow  side  of  the  knee  is  brought  almost 
into  contact  with  it,  at  once  removes  the  in-knee  distortion. 
Under  these  favouring  circumstances,  if  the  child  be  under 


Fig.  45. 


118 


IN- KNEE    DISTORTION. 


Fig.  46. 


the  age  of  two  years,  suitable  manipulations  and  mechanical 
appliances  will  effect  entire  recovery  within  from  two  to 
four  months.    If  between  two  and  four  years 
old  the  time  required  may  extend  from  three 
to  six  months,  the  child  not  needing  after- 
wards any  retentive  apparatus.     The  hand- 
ages  should  be  lightly  sewn  in  all  directions 
to  prevent  ingenious  and  curious  little  fingers 
undoing  and  loosening  them.     They  never 
require  to  be  tightly  applied.     They  should 
be  removed  night  and  morning  for  the  pur- 
poses of  cleanliness   and   ablution,  for  the 
practice  of  the  manipulations,  described  p. 
114,  and  for  a  sinr/le  hendiiig  of  the  joint 
night  and  morning,  whilst  the  nurse  sedulously  supports  with 
one  hand  the  internal  parts  of  the  joint.    They  should  be  re- 
applied with  as  little  delay  as  possible.    The  parent  or  nurse, 
after  being  once  or  twice  shown  the  manner  of  applying 
the  splints,  should  have  no  difficulty  with  them.    If  circum- 
stances permit,  the  services  of  a  trained  rubber  and  mani- 
pulator of  distortions  may  be  obtained  for  this  part  of  the 
treatment ;  the  child  being  allowed  to  spend  nearly  all  its 
time  on  the  floor.     It  should  not  be  allowed  to  stand  un- 
supported by  splints  until  the  deformity  is  seen  to  have 
disappeared,  even  after  the  splints  have  been  removed  from 
the  limbs  for  some  hours. 

If  treatment  has  been  neglected  it  will  be  found  that  in 
children  between  the  ages  of  five  and  ten  years  the  elastic 
nature  of  the  resistance  to  replacement,  above  mentioned, 
has  gradually  given  place  to  a  more  rigid  condition  of  the 
structures  on'the  outside  of  the  knee  joint.  Irons  should 
in  this  case  be  substituted  for  the  wooden  splints.  It  is  indis- 
pensable to  prompt  success  that  these  should  at  first  permit 
no  movement  at  the  knee  joint.  In  the  use  of  irons,  as  of 
splints,  the  surgeon  should  remember  that  the  gentle  con- 


TREATMENT    BY   IRONS. 


119 


DlACEAM    C. 


tinuous  force  employed  in  knock-knee  should  operate  simul- 
taneously in  two  directions,  viz.,  from  before,  backwards,  in 
order  to  prevent  bending  of  the  knee ;  and  from  within, 
outwards,  to  prevent  inward  yielding  of  it.  To  fulfil  these 
objects  the  "  irons  "  should  be  furnished  for  each  knee  with 
a  double  firm  buck-skin  knee  strap,  so  attached  and  secured 
that  one  part  shall  prevent  flexion,  the  other  shall  prevent 
inward  yielding.  The  gradual  straightening  of  the  knee 
should  be  accomplished  by  the  gradual  tightening  of  this 
double  strap.  During  the  first  few  days  and  nights  the  in- 
struments should  be  uninterruptedly  worn.  They  should  be 
so  made  as  to  permit  a  soft,  light, 
loose,  proper  shoe  to  be  substituted 
at  night  for  the  day-walking  boot, 
without  removal  of  the  knee  part 
of  the  apparatus.  In  these  cases 
no  confinement  to  the  house  is  re- 
quired, walking  in  moderation  may 
be  permitted.  At  the  present  day 
such  irons,  either  single  or  double 
to  each  leg,  are  obtainable  at  most 
instrument  makers.  The  annexed 
instrument  (diagram  c)  may  be 
relied  upon  for  the  straightening 
of  even  the  worst  adolescent  cases. 
The  patients  soon  become  accus- 
tomed to  the  inconvenient  method 
of  ascending  stairs  and  sitting 
with  stiff  knees,  and  end  by  ac- 
quiring a  dexterity  in  performing 


DiAGEAM  c. — Schematic  representation  of  ^calking  and  night  imtrument  for 
rectification  of  severe  adolescent  knock-knee..  It  consists  of  an  upright  stem, 
with  free  movement  joints  at  hip  and  ankle,  attached  heloiv  to  an  ordinanj  foot- 
piece,  and  transferable  to  an  ordinary  day  boot,  to  which  it  may  be  secured  by 
a  spring  below  the  heel :   (ci  a)  on  the  upright  stem  are  pads  on  the  fulcra  to 


120  IN-KNEE    DISTORTION. 

protect  the  skin  over  the  trochanter  <ui(J  the  e.rtermil  maUeolus  from  j/re^fxre  ; 
(d)  0)1  the  hixide  of  the  laiee  /x  to  iiidicnti'  u  pml  to  protect  this  part  from  pres- 
xitre.  Leodiii;!  from  tltis  pitil  In  tlie  upriijlit  stem  is  a  iiietnl  boek-pieee,  eonsist- 
in<i  of  two  ports,  the  h'ft-linnd  lidlf  iH'inii  the  feiiuile  screw,  and  the  ri(jht  half  a 
vuile  screw.  Ihj  tarninij  ronnd  the  piece  of  metal  (d  a  d),  to  which  the  male  screiv 
is  atliiriieil,  tliis  is  iiimie  In  enter  tlie  female  srreir,sii  Ihal  iinidiialh/  the  pad  {a) 
opposite  tlie  inside  of  tlie  knee  is  approsinuited  to  the  itpriijlit  stem,  and  the 
inrerted  knee  joint  (iradnalli/  directed  towards  tlie  perpendienlar.  If  the  knee 
he  more  inverted  than  tlie  above  dotted  ontline  represents,  tlie  treatment  sjnmld 
be  commenced  witli  tlie  use  of  a  proportionate! ij  lonrier  male  screw.  In  the  ease 
of  both  lindis  beinii  so  severeh/  affected,  it  will  he  nnirc  convenient  to  treat  the 
patient  reeundjent,  by  mean-s  of  an.  apparatus  on  the  principle  of  the  diagram  d, 
(//;//■/  //('  attain-:  a  sufficiently  improved  state  to  sit  up  or  move  about.  To  avoid 
encuniberiiifi  tlie  drawiny  several  adjuvant  essential  contrivances  hare  been 
omitted.  These  are  a  padded  metal  band  and  a  thiyh  strap,  wliich  should 
be  attached  to  the  upriyht  stem,  opposite  the  middle  of  the  thlyh,  to  draw 
the  thiyh  towards  the  perpendicidar ;  a  similar  band,  and  strap  should  he 
opposite  tlie  middle  of  the  ley.  Besides  these  a  stout  buck-skin  strap  should 
pass  from  the  upriyht  at  {b  b)  successively  over  the  front,  the  inside,  and 
around  the  back  of  the  knee,  and  be  hackled  on  the  upriyht  at  {b  h),  so 
as  to  draw  the  knee  outwards  ,•  and  another  huck-skin  strap  pass  from 
the  buckles  (c  c)  to  the  buckles  at  (d  d),  so  as  to  keep  the  knee  completely 
extended.  If  all  these  contrivances  are  yradually  hrouyht  duriny  the  first  few 
days  to  a  state  of  sufficient  tension  and  pressure,  the  patient  will  e.iperietwe  no 
pain,  excoriation,  or  undue  pressure;  the  knee  even  in  stout  adolescents  ivill  he 
completely  straiyldened.  It  is  desirable  that  once  a  day  the  knee  in  the  still- 
growiny  individual  be  bent,  so  as  to  avoid  stiffening  of  the  joint  in  the  extended 
position.  It  is  well  to  order  the  apparatus  to  have  a  riny-catch  knee  movement. 
If  the  knee  of  the  worst  class,  ichether  or  no  section  of  biceps  femoris  has  been 
done,  he,  as  it  should  be,  straiyhtened  within  eiyht  or  ten  weeks,  the  patient 
may  he  allowed,  by  means  of  the  riny-catch,  to  walk  with  free  movement  of  the 
joint  apart  of,  or  after  a  time  the  loliole  of,  the  day. 

what  at  first  were  difficult  and  inconvenient  feats  of 
activity. 

We  venture  here  to  insist  that  the  surgeon  should  no 
more  entrust  a  surgical  instrument  maker,  "l)one-setter," 
or  nurse,  to  direct  the  patient  or  the  friends  in  what  manner, 
at  what  time  or  rate,  gentle  force  is  to  be  applied  to  a  dis- 
torted knee,  than  he  would  entrust  such  persons  to  set  a 
broken  bone,  or  to  restore  to  the  proper  form  a  badly  united 


PEINCIPLES    OF   MECHANICAL   TREATMENT.  1^1 

one ;  as  much  knowledge  of  anatomy  and  pathology  as  is 
possessed  by  the  qualified  medical  practitioner  is  as  neces- 
sary in  one  case  as  in  the  other.  Some  of  our  surgical 
brethren  who  have  justified  resort  to  unnecessary  ablation  of 
tarsal  bones  in  congenital  varus  in  young  children,  or,  the 
performance  of  osteotomy  in  juvenile  cases  of  knock-knee, 
on  the  ground  of  "ordinary  orthopaedic  treatment,"  having 
failed,  have  confounded  the  previous  handing  over  of  cases 
to  the  mechanic  ignorant  of  anatomy  and  pathology  with 
the  treatment  which  should  have  been  carried  out  by  the 
orthopaedic  surgeon,  if  they  themselves  felt  unable  or 
ashamed  to  accomplish  it.  The  shades  of  Leonardo  da 
Vinci,  Camper,  Scarpa,  and  Stromeyer — who  have  all  given 
their  attention  to  distortions,  and  the  mechanical  means  of 
relieving  them — might  rise  up  against  this  disregard  of  the 
saying  of  the  noble  Koman  :  "  Homo  sum,  nihil  humani  a 
me  alienum  puto." 

Irons  often  have  failed,  because  owing  to  their  mode  of 
construction  they  have  acted  as  helps  to  locomotion,  rather 
than  as  curative  agents.  We  see  other  splints  constructed 
for  cure  of  severe  in-knee  exhibiting  just  pretensions  of 
superior  fitness,  having  regard  to  the  necessity  of  drawing 
the  knee  outwards,  but  without  any  effective  contrivance  for 
maintaining  a  completely  extended  state  of  the  joint  whilst 
the  morbid  inversion  is  being  counteracted,  or  for  prevent- 
ing the  rotation  forwards  and  outwards  of  the  whole  mem- 
ber, and,  as  is  especially  noticed  by  C.  Hueter  {op.  cit.),  of 
the  internal  condyle. 

Many  years  ago  we  introduced  into  use  here  a  metal 
splint,  adapted  to  the  outer  side  of  the  in-knee,  furnished 
with  a  rack  and  pinion,  or  endless  screw,  for  gradually 
drawing  the  knee  outwards,  similar  to  that  which  has  been 
figured  by  Volkmann  {op.  cit.).  We  found,  however,  that 
by  its  not  being  attached  to  the  foot  and  hip  it  became  dis- 
placed, through  the  internal  condyle  and  the  limb  generally 


1±1 


IN-KNEE    DISTORTION. 


DlA(iKA.M    11 


■working  round  in  an  outward  direction.  Moreover,  this 
apparatus  does  not  advantageously  permit  locomotion,  for 
the  Nveight  of  the  trunk  destroys  the  regulating  machinery, 
necessitates  repairs,  causes  arrest  of  progress,  consequent 
relapse,  and  loss  of  progress  already  made. 

It  is  remarkable  how  little  regard  to  the  simplest 
mechanical  principles  is  frequently  shown  by  instrument 
makers,  and  apparently  acquiesced  in 
by  surgeons.  Not  unfrequently  we  see 
a  side  splint  for  in-knee  of  the  rela- 
tive length,  shown  by  the  dark  line 
A  to  A  (diagram  d),  furnished  with  a 
proper  adjusting  screw  at  the  angle  of 
the  inclined  knee,  c,  and  secured  to 
the  knee  by  suitable  straps.  Whatever 
beneficial  influence  can  be  effected  by 
so  short  a  splint  as  that  indicated  by 
the  dark  line,  and  the  benefit,  as  the 
result  has  shown,  has  been  very  small, 
because  of  the  shortness  of  the  lever- 
age, and  the  absence  of  any  means  of 
completely  preventing  bending  of  the 
joint,  becomes  many  times  augmented 
by  increasing  the  leverage,  as  from 
B  to  B.  The  efficacy  of  the  apparatus 
is  still  further  increased  by  extending  it  to  the  hip  above 
and  to  the  foot  below. 

It  is  not  to  be  wondered  at  tluit  Linhart,  for  example 
(oj).  cit.,  p.  92),  should  write  : — "  I  will  not  state  that 
orthopaedic  instruments  are  useless,  but  I  do  maintain  that 
when  anything  is  gained  it  has  only  been  after  years'  use 
of  them,  and  only  when  tliroufili  the  most  carefid  application 
of  tliem  a  change  of  nutrition  in  the  bones  can  be  obtained, 
i.  6'.,  in  youth  ;  in  all  other  cases  the  surgeon  must  content 
himself  with  a  slight  amendment,   or  the   prevention   of 


PEINCIPLES    OF    MECHANICAL    TREATMENT.  123 

further  mischief"  (the  italics  are  ours).  "  In  no  case,  except 
one,  a  boy  eight  or  nine  years  old,  have  I  seen  a  cure 
effected."  Or  that  Mikulicz  {op.  cit.,  p.  707)  should  assert, 
from  his  experience,  that  in  treating  considerable  de- 
formity mechanic  ally  with  a  side  splint  the  time  required  to 
effect  a  cure  is  from  120  days  to  7  years.  Unfortunately  he 
did  not  discover  that  the  omission  of  a  back  splint  to  pre- 
vent bending  of  the  knee,  and  excluding  the  hip  and  foot  from 
the  apparatus,  were  fatal  to  his  attempts  at  cure  of  severe 
cases.  Mikulicz  actually  fixed  the  hip  joint  by  a  jolaster  of 
Paris  bandage.  Most  surgeons  have,  by  this  time,  dis- 
covered the  inconveniences  of  plaster  of  Paris  as  compared 
with  other  available  materials. 

In  the  severest  adolescent  cases,  where  the  feet  are 
separated  twenty  inches  and  upwards,  the  treatment  may 
be  commenced  by  a  metallic  or  wooden  ordinary  fracture 
box,  regulated  by  a  lateral  ratchet  screw,  and  the  apparatus, 
diagram  c,  p.  119,  be  substituted  when  the  limb  has,  in  the 
course  of  two,  three,  or  four  weeks,  been  brought  into  so 
improved  a  position  that  the  walking  apparatus  can  be 
fitted  without  violence  to  the  limb. 

It  might  reasonably  be  apprehended  by  some  surgeons 
that  by  permitting  necessary  walking  to  a  patient  with  in- 
knee,  not  straighter  than  the  dotted  outline  (diagram  c),  the 
weight  of  the  trunk  would  mischievously  interfere  with  the 
treatment.  We  regard  some  exercise  (in  the  open  air,  if 
possible)  as  a  necessary  part  of  the  treatment  in  adolescents ; 
and  especial  experience  has  abundantly  shown  us  that, 
although  the  weight  of  the  trunk  borne  on  the  limb  is  an 
obstacle,  the  cases  steadily  mend  if  the  apparatus  be  con- 
structed and  employed  upon  the  principles  we  have  laid 
down.  It  cannot  be  too  often  repeated  that  when  we  have 
to  treat  a  severe  distortion  it  is  not  necessary  to  resort  to 
tight  bandaging,  tight  buckling  of  straps  and  apparatus, 
i.  e.,  severe  treatment.     We  find  it  desirable  to  maintain 


124 


IN-KNEE    DISTORTION. 


the  slightest  possil)le  strain  upon  the  resisting  limb,  to 
have  the  curb  tangible  but  comparativel}^  loose,  not  to 
attempt  too  rapid  an  advance,  less  complaint  of  pain, 
chafing,  or  pressure-wounds  should  necessitate  relaxation 
or  suspension  of  treatment.  We  laid  down  the  rule  of  /irte 
non  vi  a  generation  ago  in  the  mechanical  part  of  the 
treatment  of  all  distortions.  It  is  as  useful,  nay  as  neces- 
sary, in  the  treatment  of  in-knee,  as  in  the  training  of  an 
unruly  animal,  a  vicious  temper,  or  an  insane  patient. 

Fig.  47. 


Aufiust  10. 


Septemher  4. 


Sejytemher  30. 


November  14. 


Blediinn  defiree  of  atonic  in-knee  of  five  years  .standinf),  from  a  serien  oj 
photoriraphis  transferred  by  photojiraphy  to  the  wood  blocks.  No  j)revious 
treatment  had  been  employed,  as  it  laid  been  expected  that  tlw  patient  inaild 
outfiron-  ''the  weakness." 

The  above  four  figures  (fig.  47)  will  well  illustrate  the 
rapidity  with  which  freedom  from  distortion  may  be  effected 
by  attention  to  the  rules  here  laid  down.  The  patient,  aged 
eight,  son  of  a  Hindoo  physician,  brought  up  partly  by  hand. 


PEOGRBSS    UNDER    MECHANICAL    TREATMENT.  125 

was  in  consequence  of  weakness  unable  to  run  alone  until  one 
year  and  half  old.  The  gait  had  continued  unsteady,  with 
proneness  to  frequent  falls.  The  father  had  discovered  no 
other  signs  of  rickets  than  the  distortion  and  debility ;  the 
general  health  had  been  in  other  respects  good.  He  was  of 
good  average  height  and  intelligence. 

Fig.  47,  No.  1,  represents  his  appearance  on  August  10th, 
when  the  treatment  by  instruments  was  commenced.  The 
only  peculiar  observation  to  be  made  regarding  the  knees, 
which  cannot  be  made  out  from  the  drawing,  is  that  they  have 
lost  the  lateral  "  play"  they  are  said  to  have  formerly  pos- 
sessed, being,  on  the  contrary,  so  accustomed  to  the  inverted 
position  that  they  cannot  be  straightened  at  once  with  the 
hands  without  giving  pain.  We  could  discover  no  trace  of 
past  rachitis,  unless  some  abdominal  fulness  were  attrir 
butable  to  that  disorder.  We  were  assured  by  the  attendants 
of  the  child  that  his  abdomen  was  not  larger  than  that  of 
the  average  child  of  vegetarian  rice-eaters  of  the  same  age. 
The  instruments  consisted  of  a  light  plain  iron  on  the  out- 
side of  each  limb,  furnished  with  free  joints  at  hip  and 
ankle,  a  "ring-catch"  movement  at  the  knee  and  a 
"stop"  to  obviate  hyper-extension,  a  double  knee-cap  as 
described  at  diagram  c  (p.  119),  but  with  a  simple,  not 
expanding,  back-piece.  The  attendants  were  shown  the 
kind  of  manipulations  required  to  be  effected.  It  was  en- 
joined that  upon  no  account  the  child  should  be  permitted 
to  stand  for  a  single  moment,  unless  supported  by  the 
apparatus.  It  was  arranged  that  a  photograph  of  the  actual 
progress  made  should  be  sent  to  us  once  a  fortnight.  As 
the  case  was  only  of  medium  severity  he  was  permitted  to 
sleep  without  the  irons.  The  dates  appended  to  each  of  the 
figures  show  a  progressive  improvement,  and  that  at  the  end 
of  nine  weeks,  November  14th,  he  could  stand  unsupported, 
no  distortion  remaining.  During  the  following  two  months 
the  ring-catch  at  the  knee  was  released  during  one-half  of 


126  IN-KNEE    DISTORTION. 

each  day,  so  that  complete  extension  of  the  knees  was  then 
only  maintained  for  half  of  each  day.  During  the  fifth  and 
six  months  he  wore  the  instruments  with  constant  free 
motion  at  every  joint,  and  then  laid  them  aside  altogether 
without  relapse. 

It  is  worthy  of  remark  that  the  grandmother,  in  whose 
charge  the  child  remained  in  the  country,  remarked,  as 
parents  in  other  cases  have  done  when  the  instruments 
have  heen  rightly  designed  and  well  adjusted,  that  he  had 
never  had  a  moment's  uneasiness  from  them ;  on  the 
contrary  had,  whilst  wearing  them,  recovered  the  natural 
huoyancy  of  his  age  and  greater  strength  than  he  had 
possessed  hefore  having  recourse  to  them. 

It  is  also  worthy  of  remark  that  children  who  have  with 
difficulty  effected  locomotion  from  in-knee  are  observed  to 
improve  in  appetite  and  strength  directly  they  feel  the 
relief  afforded  by  the  support  of  the  apparatus.  In  fact, 
with  the  help  of  support  they  are  enabled  to  take  much 
more  healthy  exercise,  and  the  economy  is  spared  the  out- 
lay which  was  occasioned  by  previous  difficult,  fatiguing,  or 
painful  efforts.  We  have  given  the  above  single  illustra- 
tion. The  same  might  have  been  done  with  adolescent 
cases.  It  is,  however,  less  easy  to  obtain  photographic 
records  of  cases  of  adolescents  of  either  sex. 

In  proportion  as  the  health  of  children  affected  with  this 
distortion  from  debility  improves,  and  especially  in  the  cases 
which  have  arisen  from  unmistakable  rickets,  in  which 
undue  hardening  of  bones  succeeds  to  delayed  ossification 
or  softening,  the  whole  of  the  fibrous  structure  acquires  an 
increase  of  firmness  and  rigidity,  so  that  between  the  ages 
of  seven  and  fourteen,  or  thereabouts,  the  question  of  the 
necessity  for  division  of  the  resisting  outer  hamstring  and 
lateral  ligament  of  the  joint  occurs.  Previously  to  1850  we 
frequently  performed  this  operation  with  satisfaction,  as  to 
the  aid  afforded  by  it  to  restoration.  The  distinct  gain  from  it 


DIVISION    OF    HAMSTRING    UNNECESSARY.  127 

was  very  evident  immediately  after  the  operation,  and  for  two 
or  three  weeks  afterwards ;  but  on  comparing  the  actual  time 
expended  upon  cases  treated  by  mechanical  means  only,  and 
those  treated  with  the  additional  help  of  division  of  tendon 
and  ligament,  the  gain  of  time  was  only  measured  by  two  or 
three  weeks  immediately  following  the  surgical  operation. 
This  did  not  compensate  either  the  operator  or  the  parent. 
It  is  a  matter  of  experience  in  the  treatment  of  this  distor- 
tion, as  of  most  physical  (as  wellas  moral)  evils,  that  it  is 
easier  to  make  a  marked  impression  upon,  and  removal  of, 
a  considerable  part  of  the  evil  when  it  is  first  attacked  than 
during  the  after  stages  of  the  treatment,  and  the  last  trace 
of  the  complaint  offers  the  strongest  resistance.  It  is  the 
omission  to  remove  this  last  trace  of  distortion  in  knock- 
knee  and  other  deformities,  whatever  the  mode  of  treatment 
selected  may  be,  and  the  consequent  premature  cessation  of 
treatment,  which  cause  so  many  relapses,  and  which  have 
encouraged  the  adoption  of  other  more  radical  measures. 

The  partial  eburnation  or  hardening  of  the  bones,  pre- 
ceded by  softening  of  them,  commonly  takes  place  at  four 
or  before  the  age  of  five  years.  It  is  therefore  necessary, 
in  the  treatment  of  rachitic  curvatures  of  bones,  to  effect 
straightening  at  an  early  age ;  any  straightening  of  them 
afterwards  will  be  very  slow,  and  will  depend  as  much  upon 
the  spontaneous  restoration  due  to  the  play  of  the  muscles 
during  use  of  the  affected  parts  as  upon  therapeutic  circum- 
stances. It  may  be  well  to  state  here  that  a  small  amount 
of  rachitic  bone  curvature  may  prevent  the  part  from 
rivalling  the  beauty  of  the  Venus  de  Medici,  yet  provided  the 
limb  as  a  general  whole,  represents  a  fairly  straight  column 
and  fairly  natural  contour  from  above  downwards,  it  need 
not  be  the  subject  of  treatment  after  the  age  of  five. 

As  regards  this  matter  the  female  has  an  advantage 
over  the  male  sex.  In  the  female  the  naturally  greater 
rotundity  in  the  form  of  the  limbs  at  puberty,  due  to  greater 


128  IN-KNEE    DISTORTION. 

deposit  of  subcutaneous  adii^ose  tissue,   serves  to  conceal 
small  amounts  of  permanent  curvature. 

The  introduction  of  the  use  of  anaesthetics  since  1850, 
and  the  resort  to  straightening  under  their  influence,  has 
been  of  service,  and,  in  our  opinion,  enables  the  surgeon  to 
limit  still  further  the  use  of  section  of  outer  hamstring  and 
the  lateral  ligament.  Although  we  have  coupled  the  biceps 
femoris  and  external  lateral  ligament  together,  experience 
leads  to  the  conclusion  that  section  of  the  ligament  is  less 
defensible  than  that  of  the  tendon.  The  ligament,  when 
elongated  by  mechanical  extension,  does  not  so  readily 
recontract  as  the  muscle,  which,  being  an  active  contractile 
organ,  may  return  to  the  struggle,  but  finally  gives  way 
when,  by  persistent  aid  of  the  apparatus,  the  antagonists 
on  the  opposite  side  of  the  limb  assert  their  balancing  in- 
fluence. Even  up  to  the  age  of  sixteen  or  seventeen,  or  so 
long  as  active  growth  is  going  on,  especially  those  cases 
which  first  present  themselves  during  adolescence  and 
over-rapid  growth,  in  which  the  feet,  being  from  twelve  to 
twenty  inches  apart,  are  placed  in  a  straight,  jointless 
iron,  worn  along  the  outside  of  the  knee  night  and  day, 
are  remedied  solely  by  mechanical  means.  No  inter- 
ference with  health  or  cessation  of  the  occupation  in  which 
the  patient  was  engaged  before  the  treatment  need  occur. 
An  aid  to  the  determination  of  the  treatment  most  de- 
sirable in  the  individual  case  is  afforded  by  the  manual 
application  of  pressure  without  or  with  the  aid  of  an 
anaesthetic.  If  the  resistance  is  felt  to  be  an  elastic  one 
when  the  joint  resistance  is  tested  without  anaesthesia,  or 
if,  with  the  help  of  anaesthesia,  the  knee  is  felt  to  yield 
with  moderate  manual  force,  the  case  may  with  confidence 
be  left  to  stead}^  continuous  unvacillating  mechanical  treat- 
ment. It  is  different  with  severe  rachitic  cases,  in  which 
the  growth  is  prematurely  arrested,  in  which  curvature  of 
bones  constitutes  the  greatest  obstacle  to  restoration,  and 


TREATMENT  BY  "  REDRESSEMENT  FORCE."       129 

in  which,  without  the  use  of  mischievous  violence,  Httle 
improvement  in  position  is  effected  by  manual  efforts. 

Vei-y  violent  straightening  of  in-knee  under  anesthesia 
has  been  largely  employed,  but  is  open  to  the  same  ob- 
jections which  apply  to  violent  methods  in  deformities  in 
general.  Those  in  use  in  the  present  day  are  due  to  want 
of  experience  and  want  of  patience.  The  violent  method  of 
reducing  distortions  was  sufficiently  tested  many  years  ago 
by  Sartorius,  Dieffenbach,  Louvrier,*  and  us.  Many  modern 
surgeons  have  employed  it  in  knee  contraction  and  knee 
inversion ;  it  has  often  resulted  in  fractured  bones,  separa- 
tion of  epiphyses,  laceration  of  ligaments,  rupture  of  popli- 
teal blood-vessels,  and  popliteal,  nerve,  and  not  the  least  of 
the  evils  produced  by  it  has  been  inflammation  succeeded  by 
"  strumous  "  disease.  Violence  thus  used  is  measureless  and 
misplaced.  When  effected  by  the  united  force  of  the  surgeon 
and  his  assistant — often  of  several  assistants — it  degenerates 
into  jerking  violence,  and  cannot  be  arrested  at  a  precise 
moment ;  it  is  misplaced  because  it  cannot  always  be  con- 
fined to  the  most  contracted  and  most  resisting  structures. 
Sometimes  we  have  operated  a  deux  temps,  and  have 
severed  the  biceps  tendon  and  the  external  lateral  liga- 
ment, and  allowed  the  small  punctures  to  unite  before 
resorting  to  violent  straightening  by  the  hand.  This  is  pre- 
ferable to  the  use  of  violence  instantly  after  section  of  the 
above  structures.  No  proof  has  been  afforded  that  with  the 
aid  of  these  proceedings  any  gain  has  resulted  to  the  patient, 
as  regards  pain,  time,  and  inconvenience,  equal  to  that 
afforded  by  the  gradual  use  of  instruments. 

The  experience  of  Billroth  t  as  to  "  redressement  force," 

*  See  Siebold's  '  Sammlung  seltener  unci  auseiieseuer  Cliii-. 
Beobachtungen,' Band  iii.,  p.  258.  Stromeyer:  'Beitriige  zur  opera- 
tiven  ortliopadik,'  p.  25.  Dieffenbacli :  '  Ueber  die  Diu'clischneidung 
der  Muskeln  und  Sehnen,'  1841.  Little :  '  Treatise  on  Club-foot  and 
Analogous  Distortions,'  Introduction,  p.  xlix.,  1839. 

f  Billrotli:  "Clinical  Sui'gery,"  'Trans,  of  New  Syd.  Soc.,'  1881. 


13U  iN-kNee  t)iST:oRTioM. 

and  as  to  section  of  the  biceps  tendon  and  the  external 
lateral  ligament,  coincides  with  that  published  by  us  a 
generation  ago. 

After  complete  straightening  of  severe  cases,  a  super- 
abundance of  tissues  on  the  internal  side  of  the  knee  may 
exist.  The  skin  and  subjacent  structures  appear  loose, 
and  favour  the  tendency  to  relapse.  This  disproportion 
does  not  long  continue  in  children,  as  from  the  growth  of 
the  limbs  the  natural  relation  becomes  established.  But  in 
adolescents  and  adults,  who  have  respectively  nearly  or 
wholly  completed  their  growth,  its  removal  is  more  slow 
and  uncertain  ;  hence  a  long  continuance  of  weakness.* 

When  such  rapid  forcible  measures  are  employed  much 
is  apparently  gained  at  the  moment,  but  apparatus  is  much 
less  easily  borne  after  such  treatment  than  without  its  use, 
and  in  the  long  run  the  tortoise  is  apt  to  outrun  the  hare. 

*  On  this  siTbject  we  M^-ote  as  follows  in  '  Treatise  on  Deformities,' 
pp.  221,  222: — "For  some  years  past  tlie  author  has  wholly  discon- 
tinued the  use  of  operation  in  genu-valgum,  lia\T.ug  ascertained  by 
comparison  of  the  time  occupied  in  treatment  with  and  without 
operation,  that,  although  with  the  operation  a  rapid  improvement  is 
at  first  visible,  the  ultimate  result  is  the  same,  whether  or  no  the 
operation  be  performed.  lu  no  other  than  adults  did  the  operation 
ever  appear  justifiable.  The  length  of  time  requisite  for  adjustment 
of  articular  surfaces  of  the  femur  and  tibia  in  severe  adult  cases 
renders  the  gain  in  the  first  instance  by  operation  of  little  moment. 
The  author  has  found  the  inversion  yield  in  the  severest  cases  within 
three  months  to  improved  mechanical  treatment,  consisting  either  of 
wooden  splints,  hinged  at  outside  of  knee,  and  straightened  by  a 
ratchet  or  male  and  female  screw,  or  with  a  strong  common  stitf  iron 
attached  to  a  shoe,  pro2)erly  adapted,  and  duly  removed  for  friction 
and  manipulations.  At  present  the  author  does  not  even  find  it 
necessary  to  confine  such  severe  cases  to  the  recumbent  position 
dm-ing  the  daytime.  He  has  treated,  with  the  aid  of  irons,  many 
adolescents  who  have  followed  sedentary  occupations  during  the 
whole  period  they  were  under  observation.  Habitual  voluntary 
flexion  of  the  knee  should  not  in  these  cases  be  permitted  until  many 
months  after  the  inversion  has  been  overcome." 


TEEATMENT  BY  "  REDBESSEMKNT  FORCK."       131 

If  force  be  absolutely  necessary  the  author  prefers  the 
most  modern  form  of  applying  force  —  supra-conclylar 
osteotomy ;  for  when  after  this  operation  the  limb  is 
secured'  in  a  straight  position,  a  gap  is  formed  on  the 
external  margin  of  the  femur  at  the  place  of  division,  and 
the  external  condyle  is  lowered  to  a  corresponding  amount. 
By  the  consequent  change  of  relation  of  the  leg  the  tibia  is 
adducted,  and  the  genu-valgum  disappears.  The  gap  in 
the  femur  artificially  made  is  substituted  as  it  were  for  the 
analogous  gap  felt  in  the  straightened  genu-valgum  in  the 
young  by  the  surgeon's  hand,  when  the  laxity  of  the  joint 
permits  the  manoeuvre.  After  Macewen's  operation  Nature 
fills  up  the  triangular  gap  in  the  femur  by  callus,  just  as 
Nature  by  a  return  to  natural  growth  where  wanted,  in  the 
femur  and  tibia,  fills  up  the  gap  between  the  external  con- 
dyle and  the  opposing  articulating  surface,  when  the 
surgeon,  with  the  aid  of  mechanical  apparatus  without 
osteotomy,  has  succeeded  in  holding  those  structures 
asunder,  so  as  to  enable  her  to  act.     See  figs.  21  and  49. 

Dr.  Shaffer*  remarks: — "If  students  were  taught  how 
to  recognise  the  earliest  stage  of  progressive  deformities  of 
all  types  the  necessity  for  surgical  operation  would  be 
further  removed ;  and  I  have  made  it  my  rule,  and  it  is  a 
good  one,  never  to  use  the  knife  to  remove  deformity  when 
I  can  avoid  it.  We  have  no  right  to  say,  I  can  accomplish 
the  removal  of  the  deformity  quicker  by  its  use.  Will  the 
ultimate  usefulness  of  the  member,  or  members,  be  greater 
if  I  remove  the  deformity  quickly,  and  merely  save  time 
thereby  ?  We  have  no  right  as  conscientious  surgeons  to  think 
of  our  time  or  effort  in  orthopaedic  practice." 

We  have  occasionally  seen  in  consultation  a  former  in- 
knee,  or  an  out-knee,  which  has  been  straightened  by 
instrumental  means,  but  which  has  remained  loose,  the 

*  Newton  M.  Shaffer;  'On  Knock-knee  and  Bow-legs,'  New 
Yuik,  18S1. 


132  IN-KNEE    DISTORTION. 

joint  structures  of  which  have  not  adapted  themselves  to 
their  new  relations,  and  sometimes  this  condition  is  accom- 
panied with  curvature  of  leg  bones.  In  these  cases,  if  the 
curvature  has  been  considerable  we  have  advised  osteo- 
tomy, and  have  succeeded  in  giving  stability  to  the  knee 
by  enclosing  it  in  leather  or  felt-paraffin  splints  and  band- 
ages, worn  night  and  day,  which  were  removed  for  an 
occasional  bending  of  the  joint.  As  soon  as  practicable 
we  have  allowed  free  motion  in  light  irons,  until  the  knees 
have  recovered  firmness  and  their  due  bearings. 

We  have  spoken  of  the  comparative  ease  with  which 
even  severe  distortions  yield  to  continuous  mechanical 
treatment,  during  which  the  member  is  not  tightly  or 
painfully  secured.  At  first  a  difficulty  in  explaining  the 
success  achieved  was  experienced.  We  considered  that  con- 
tinuous gentle  action  of  the  instrument  acted  solely  after 
the  manner  of  dropping  water  upon  stone ;  but  we  were 
gradually  enabled  to  perceive  that  the  patient's  muscles  on 
the  uncontracted  side  of  the  member  assist  replacement. 

A  proof  of  the  aid  given  to  recovery  by  the  muscles  on 
the  uncontracted  side  of  the  limb  is  afforded  by  the  follow- 
ing fact,  sometimes  spontaneously  mentioned  by  a  patient 
as  respects  the  knee,  when  it  is  being  brought  by  instru- 
mental treatment  from  the  bent  partially  ankylosed  state 
to  a  straight  position.  A  few  days  after  the  limb  has  been 
placed  in  a  "ratchet"  or  "rack  and  pinion"  extension 
apparatus,  and  progress  to  the  amount  of,  say,  10  to  15 
degrees  has  been  made,  the  patient  may  feel  what  he 
describes  as  a  tremulous  movement  in  the  patella  and  its 
ligament  attached  to  the  tibia,  which  is  due  primarily  to 
the  previously  stretched  elongated  condition  of  the  quadri- 
ceps femoris,  and  its  connected  patella  and  ligament  having 
been  relaxed  and  loosened,  now  that  the  joint  has  been  some- 
what straightened.  The  quadriceps  femoris,  after  months  or 
years  of  previous  disuse,  consequent  upon  the  knee  disease 


SUCCESS    OF    TREATMENT    BY    POSITION.  133 

and  contraction,  feels  itself,  now  that  it  is  loosened,  out  of 
gear,  as  it  were,  and  only  after  a  series  of  tremulous  weak 
efforts  adapts  itself  to  its  reduced  range.  In  like  manner, 
in  in-knee,  the  sartorius  and  gracilis  may  help  restoration 
when  the  opportunity  is  offered  them. 

We  shall  rejoice  if  any  words  of  ours  shall  lead  to  the 
employment  of  gentle  means.  Violence,  proved  to  be  un- 
necessary, is  to  be  regarded  as  a  wrong  ignorantly  inflicted, 
inasmuch  as  other  well-approved,  long-practised,  successful 
gentle  means  are  available  for  restoration.* 

A  long  continued  experience  has  shown  that,  to  cure  in- 
knee,  besides  diet  and  hygiene,  two  things  are  necessary, 
inz.,  to  keep  the  knee  extended  during  the  treatment  by  an 
unyielding  apparatus,  to  employ  a  similar  contrivance  to 
maintain  adduction  of  the  leg.  Also  by  recognising  the 
necessity  of  relieving  the  external  condyle  and  the  opposing 
part  of  the  tibia  from  pressure,  in-knee  has  even  been 
arrested  by  its  being  maintained  in  a  bent  position,  as  when 
a  boy  has  been  apprenticed  to  a  tailor,  in  the  work  of  which 
the  patient  should  sit  a  la  Turque,  or  as  by  Hueter's  plan, 
described  p.  113.  In  the  elastic  stage  of  in-knee,  riding 
astride,  without  stirrups,  on  a  narrow-backed  donkey, 
Shetland  pony,  or  rocking-horse  is  a  valuable  aid  to  cure. 
Eiding,  where  available,  may  in  many  severe  cases,  be 
resorted  to,  at  daily  intervals,  removal  of  instruments  being 
then  permissible.  In  such  cases  the  patient  should  not  be 
allowed  to  stand  or  walk  unsupported  b}^  apparatus,  until  it 
is  ascertained  that  it  can  be  done  without  the  knees  again 
giving  way. 

Infants  even,  who  cannot  walk,  evince  no  pain  or  incon- 
venience from  the  treatment,  it  being  permitted  them  to 
spend  their  day  upon  the  floor  ;    in  them  the  apparatus 

■■'  Dr.  Buckminster  Brown,  of  Bostou,  U.S.,  lias  published  illus- 
trations of  cases  successfully  treated  by  instruments :  '  Orthopaedic 
Surgery,'  1S3S, 


134  IN-KNEE    DISTORTION. 

may  also  be  removed  for  a  couijle  of  hours  night  and  morn- 
ing. We  would  remind  the  surgeon  of  an  axiom  of  John 
Bell,  "applicable  to  our  present  subject,  to  the  effect  that 
"  force  is  only  successful  where  it  is  not  needed."  If  the 
utmost  gentleness  be  used  Nature  will  do  her  work  with  the 
utmost  docility.  All  bandages  and  straps  require  to  be 
applied  with  a  comparative  looseness  that  may  seem  ridi- 
culous to  the  inexperienced.  Children  of  two  or  three  years 
and  upwards,  able  to  walk,  may  wear  the  apparatus  day  and 
night,  and  walk  about  as  much  as  they  like  in  the  daytime 
with  reasonable  rest,  the  apparatus  being  removed  morning 
and  evening  for  a  feio  minutes  only  for  cleanliness  and  to 
enable  the  nurse  twice  daily,  as  directed,  to  bend  the  knee- 
joint  once. 

Mechanical  treatment  which  can  be  carried  out  by  the 
mother  and  nurse  when  properly  instructed  and  watched  by 
the  surgeon  is  the  proper  remedy  for  all  cases  of  in-knee  in 
early  childhood,  whether  rachitic  or  not.  The  greater  num- 
ber of  young  adolescent  cases  of  genu-valgum,  when  taken 
in  time,  are  also  quickly  recoverable  without  the  use  of 
violence  and  without  osteotomy. 

In  all  cases  the  patient  may  follow  his  nursery,  school, 
or  business  vocation.  As  soon  as  it  is  found  that  the  knees 
evince  no  decided  tendency  to  return  to  the  valgus  form 
directly  the  controlling  apparatus  is  removed,  a  gradually 
extended  permission  to  habitually  use  the  parts  in  full 
mobility  may  be  given. 

It  is  rarely  necessary  in  any  but  the  severely  neglected 
or  unrelieved  cases,  even  in  the  adolescent  up  to  the  age  of 
sixteen  or  seventeen,  to  confine  the  patient  to  the  couch  or 
bed.  If  an  in-knee,  which  is  not  one  of  the  slightest  degree,  be 
temporarily  obliterated  by  the  use  of  splints  or  irons  without 
the  knee  having  previously  been  extended  in  the  true  direc- 
tion, i.e.,  the  patella  presenting  forwards  when  the  patient 
stands  up,  the  straightening,  ^'.c,  the  removal  of  the  dis- 


FIXATION    OF    KNEE    IN    THE    EXTENDED    POSITION.  IBS 

tortion,  is  only  apparent.  It  will  be  found  that  a  rotation 
of  the  limb  on  its  axis,  at  the  hip,  has  taken  place,  owing 
to  which  the  popliteal  region  presents  more  or  less  inwards 
instead  of  backwards,  and  the  patella  presents  outwards. 
We  discovered,  many  years  ago,  the  necessity  of  basing  the 
instrumental  rectification  upon  preliminary  fixation  of  the 
knee  in  the  extended  position,  and  have  been  interested  by 
finding  that  Amesbury,  before  us,  plainly  recognised  this 
necessary  preliminary.  Ignorance  of  it  explains  the  fact  that 
many  able  surgeons  who  have  written  on  orthopaedic  sub- 
jects have  entirely  failed  in  their  instrumental  treatment. 

It  is  lamentable  that  surgeons  have  not  investigated  and 
discovered  the  cause  of  their  own  failure,  and  carefully 
applied  instruments  themselves  or  superintended  as  well  as 
directed  their  application,  and  in  fact  given  as  much  care 
to  the  "  setting  "  of  a  distorted  as  of  a  broken  limb.  The 
surgeon  has,  in  fact,  too  often  handed  the  case  to  the 
instrument-maker  ;  if  the  surgeon  had  personally  treated 
it,  he — being  then  responsible  as  to  instruments — might 
have  discovered  the  cause  of  his  want  of  success. 

A  certain  superciliousness  on  the  part  of  many  surgeons 
towards  any  mode  of  treatment  not  carried  out  under  their 
own  eyes  in  their  own  j^articular  hospital  has  been  a  feature 
(we  will  hope)  of  the  departing  generation  of  surgeons. 

Volkmann  (op.  cit.),  a  surgeon  of  European  reputation, 
has  thought  it  necessary  to  apologise  when  detailing  the 
shape  and  qualities  of  the  orthopaedic  instruments  he  has 
employed  and  depicted.  Surgeons  omit  any  similar  apology 
when  describing  the  particular  catheter  or  lithotrite  em- 
ployed. We  fail  to  see,  in  a  matter  of  humanity  and  pro- 
fessional occupation  in  the  relief  of  suffering,  why  apology 
was  not  as  much  needed  in  the  instance  of  one  set  of  instru- 
ments as  of  the  other.  The  apology  was  a  relict  of  the  day 
when  the  physician  only  condescended  so  far  as  to  direct 
the  barber,   surgeon,   or  bone-setter  what  he    should  do, 


136  IN-KNEE    DISTORTION. 

forgetting  the  ancient  Scaying  of  Pliny  already  quoted.  It 
reminds  us  of  a  much  later  day  when  we  heard  an  able 
operating  surgeon  say  that  "  he  left  the  prescribing  of 
drugs  to  the  physician.," 

It  is  found  even  in  advanced  adolescent  cases,  that  if  the 
mechanical  treatment  be  continuous  day  and  night  for  three 
or  four  weeks,  or  in  most  severe  cases  until  the  limb  is 
straight,  no  advance  of  screw  or  strap  being  permitted  by 
the  surgeon  until  the  previous  advance  has  been  thoroughly 
well  borne,  considerable  exercise  with  stiff  knees  may  often 
be  allowed  during  the  second  month  of  mechanical  treat- 
ment. The  effect  of  this  liberal  exercise  in  the  straight 
position  is  to  bring  about  such  a  change  in  the  articular 
surfaces  of  the  femur  and  tibia  as  will  fit  them  for  future 
correct  locomotion  without  irons.  The  change  in  question 
consists  in  renewed  growth  of  the  cartilage  and  bone  on  the 
outer  half  of  the  articulating  surface,  and  probably  absorp- 
tion and  reduction  in  length  of  the  internal  corresponding 
parts  of  the  joint. 

Whatever  change  the  ligaments  have  undergone  (p.  38) 
is  at  the  same  time  rectified,  undue  length  of  ligaments  on 
one  side  of  the  joint,  and  unfolding  (see  p.  41)  and  length- 
ening of  ligaments  on  the  outer  side  taking  place. 

Fig.  48  represents  the  thigh  and  leg  bones  of  a  child  or 
young  adolescent,  from  Mikulicz,  affected  with  in-knee,  and 
especially  the  relations  of  the  femur  and  tibia,  and  of  their 
respective  epiphyses.  It  exhibits  increased  abnormal  growth 
of  the  internal  diaphysial  part  of  the  femur,  and  of  the  ad- 
jacent part  of  the  epiphysis.  The  increase  of  these  parts 
is  more  apparent  than  real,  because  Mikulicz  has  made  no 
allowance  for  smallness  of  the  external  condyle,  which  is 
due  to  arrested  development  or  absorption,  consequent  on 
compression. 

At  fig.  49  we  have  placed  the  same  bones  in  their 
proper  relation  for  a  sound  limb,  by  which  is  shown  the 


RENEWED  GROWTH  OF  BONE. 


137 


gap  which  would  exist  between  the  external  condyle  and 
the  opposite  articular  surface  of  the  tibia  but  for  the 
dotted  outlines  which  we  have  added  to  the  outer  parts 


Fig.  49. 


The  femur  in  fig.  49  has  been  represented  as  too  upright. 

of  the  articular  surfaces,  in  order  to  show  the  natural 
growth  of  these  parts,  which  ensues  when  the  limb  is 
restored  by  proper  mechanical  treatment. 

At  the  third  month  of  the  treatment  in  severe  adult 
cases  the  patient  when  seated  may,  by  means  of  the 
"ring-catch,"  remain  with  his  knees  flexed  or  extended 
at  will.  When  he  regains  the  erect  posture,  or  is  walk- 
ing, the  surgeon  should  allow  half  of  the  exercise  to  be 
effected  with  free  motion  of  the  joint,  and  half  in  the  fixed 
extended  position.  With  these  precautions  the  muscles 
are  gradually  educated  to  correct  relations,  action,  and 
strength,  and  the  passive  structures  (ligaments  and  bones) 


138  IN-KNEE    DISTORTION. 

are  tended  and  assisted  to  resume  their  natural  bearings 
and  functions. 

Even  at  the  end  of  the  third  month  the  curiosity  and 
desire  of  the  parent  and  adolescent  patient  to  ascertain 
whether  locomotion  can  be  spontaneously  and  properly 
effected  without  the  aid  of  apparatus  should  not  be  in- 
dulged. Whilst  the  orthopaedic  surgeon  is  assisting  Nature 
to  effect  a  cure  by  restoring  the  normal  relation  of  parts  in 
form,  position,  and  strength,  so  that  the  influence  of  gravity 
can  be  properly  withstood,  he  can  no  more  tolerate  "  play- 
ing fast  and  loose  "  during  mechanical  treatment  of  in-knee 
than  he  can  when  conducting  the  mechanical  treatment  of 
a  broken  bone. 

The  vulgar  mind  considers  that  the  "  doctor  "  has  exhi- 
bited a  mysterious  skill,  when  the  surgeon  or  the  bone- 
setter  has  placed  broken  bones  in  their  natural  relation,  and 
endeavours  to  maintain  them  in  a  right  position  by  mecha- 
nical or  instrumental  treatment,  and  readily  comprehends 
the  necessity  of  some  weeks'  persevering  retention  of  them 
in  the  natural  situation.  In  like  manner  they  are  easily 
led  to  understand  the  reasons  for  the  necessity  of  the 
precautions  to  be  followed  in  the  management  of  serious 
distortions,  if  the  surgeon  understands  the  work  in  hand, 
takes  the  trouble  to  firmly  explain  his  operations  to  the 
patient  and  friends,  and  the  certainty  of  success  if  they  do 
not  "play  fast  and  loose"  with  the  apparatus  and  the  limb. 

We  have  said  and  written  much  on  the  necessity  of 
gentleness  and  perseverance  on  the  part  of  the  surgeon  and 
his  subordinates.  We  may  add  that  technical  tact  and 
mental  tact  and  confidence  are  necessary  on  his  part. 

We  can  afdrm  that  the  worst  cases  of  in-knee  may  be 
effectually  restored  by  the  above  means,  and  when  the  case 
mainly  depends  upon  knee  deviation.  The  case  is  different 
when  the  shafts  of  the  long  bones  are  much  bent  and 
eburnation  of  them  is  far  advanced. 


PEEVENTION    OF    THIS    DISTORTION.  139 

We  have  for  many  years  practised  without  seeing  an 
abrasion,  bruise,  or  superficial  slough,  or  even  disturbance 
of  sleep  at  night,  during  the  treatment  of  this  complaint, 
after  the  first  or  second  night's  use  of  suitable  apparatus. 

We  have  shown  (p.  116)  that  many  cases  before  the  age 
of  seven  or  eight  are  so  rapidly  straightened,  and  the  parts 
so  rapidly  re-adapted  for  correct  use  and  restored,  that  in  a 
few  weeks,  or  in  two  or  three  months,  they  may  be  permitted 
to  stand  alone,  and  take  some  exercise  unsupported  by  appa- 
ratus. In  advanced  adolescence  and  adult  age  the  patient 
needs  to  wear  his  "  supports,"  whilst  freely  using  his  limbs, 
from  six  months  to  one  or  two  years.  We  have  never 
known  the  most  severe  case  wear  them  beyond  two  years, 
although  we  have  been  consulted  in  cases  where  mechanical 
treatment,  injudicious  in  its  character  and  application,  had 
been  ineffectually  used  for  several  years.     See  p.  30. 

When  permission  to  stand  and  walk  unsupported  has 
been  granted,  the  case  needs  to  be  watched,  lest  inversion 
should  return  owing  to  over-exercise,  or  through  omission 
of  the  manipulations,  rubbings,  and  special  movements 
and  postures,  which  have  been  recommended  for  the  early 
stages.     We  have  never  seen  it  return. 

This  distortion,  except  in  the  very  rare  congenital  in- 
stances, is  always  preventible.  It  is  one  of  the  advantages 
of  having  become  acquainted  with  the  etiology  and  morbid 
anatomy  of  each  variety  of  this  physical  change  of  form, 
and  of  the  manner  in  which  Nature,  when  assisted  by  art, 
effects  a  cure,  that  the  medical  practitioner,  when  con- 
fronted by  infantile  weakness  and  relaxation  during  rapid 
growth,  by  retarded  independent  locomotion,  by  rickets,  by 
knee  injury  from  accident,  disease,  or  rheumatism,  and 
other  causes  mentioned  in  these  pages,  knows  that  amongst 
other  probabilities  he  may  anticipate  the  occurrence  of 
more  or  less  morbid  knee  inversion  and  aggravation  of  his 
patient's  condition,  and  can  by  judicious  measures  prevent 


140  IN-KNEE    DISTOETION. 

its  occurrence,  or  obviate  its  increase  when  the  slightest 
manifestation  of  it  is  present.  The  arrest  of  the  earliest 
stage  may  be  accomplished  by  manipulations  and  other 
gentle  means,  which  we  have  enumerated  (p.  109  et  seq.). 
Few  maladies,  in  short,  are  so  easily  preventible  through 
the  co-operation  of  the  surgeon  and  parent  as  this  distortion. 
This  is  especially  true  of  such  deformities  as  we  have  caused 
to  be  pictured  in  the  earlier  pages  of  this  work.  This  being 
the  case  we  might  venture  to  predict  that  after  the  lapse  of 
a  few  years,  owing  to  our  teaching  and  that  of  contempo- 
raries, such  specimens  of  in-knee  distortion  will  only  be 
found  in  anatomical  museums  or  libraries,  and  that  violent 
methods  of  treatment,  and  sundry  surgical  operations  now 
employed,  will  be  immediately  recognised  as  inapplicable. 

Nearly  thirty  years  ago  (Little,  '  On  Deformities,'  p.  267), 
speaking  of  severe  congenital  varus,  we  expressed  ihe  opinion 
that  a  generation  later,  the  representations  of  inveterate 
congenital  club-foot  given  in  that  work,  might  have  only  a 
historical  value.  We  might  have  written  the  same  of  adult 
severe  in-knee.  We  were  then  too  sanguine.  It  is  the 
misfortune  of  humanity,  and  of  our  profession,  that  although 
much  improvement  has  been  accomplished,  the  sanguine 
hopes  of  1853  have  not  been  realised.  May  we  on  the  pre- 
sent occasion  be  more  successful  in  stimulating  society  and 
the  profession  to  render  impossible  amongst  the  needy 
classes  these  forms  of  severe  distortion,  which  it  has  been 
the  lot  of  the  present  generation  to  witness  ! 

Having  asserted  the  practicability  of  remedying  the 
most  severe  cases  of  adolescents  and  adults  by  mechanical 
means  only,  there  remains  to  be  considered  the  advisability 
of  depending  upon  those  means,  now  that  by  the  combined 
influence  of  Esmarch's  mode  of  rendering  operations  blood- 
less, of  Lister's  antiseptic  treatment  of  wounds,  and  of  the 
proofs  afforded  by  Macewen's  large  personal  experience  of 
osteotomy  operations,  the  almost  absolute  safety  with  which 


WHEN    OSTEOTOMY   IS    DESIRABLE.  141 

section  of  the  thigh  and  leg  bones  can  be  effected  has  been 
shown. 

We  published  the  particulars*  of  the  first  osteotomy 
operation  for  a  deformity,  performed  in  this  country  by 
Mr.  L.  Stromeyer  Little,  at  the  National  Orthopsedie  Hos- 
pital in  1865,  and  ventured  to  predict  that  in  a  few  years 
osteotomy  would  become  a  standard  operation  of  surgery. 
This  first  operation,  on  an  adult  female  in  both  lower  limbs, 
performed  with  the  saw  by  open  wounds,  was  successful  as 
to  the  removal  of  distortion,  and  recovery  of  power  of  walk- 
ing erect.  In  the  first  leg  some  suppuration  and  constitu- 
tional disturbance  occurred.  The  second  limb  was  operated 
on  after  recovery  from  the  first.  As  the  result  of  acquired 
experience  very  slight  suppuration  or  disturbance  of  health 
took  place  in  the  second.  The  exchange  of  the  saw  for 
the  chisel  in  an  operation  for  knee  ankylosis,  in  1868, 
by  Mr.  Little,!  has  led  the  way  in  this  country  to  the 
substitution  of  the  latter  wherever  practicable,  and  we  see 
the  fruits  of  the  substitution  of  it,  aided  by  the  method 
of  bloodless  and  antiseptic  surgery,  in  the  success  which 
has  attended  Macewen,  exhibiting  a  mortality  after  his 
operations  of  less  than  half  per  cent. 

We  had  a  voice  in  the  above  operations,  but  do  not  base 
the  opinions  we  possess  on  the  necessity  for  osteotomy  upon 
the  number  of  cases  we  have  personally  carried  out,  for, 
with  the  exception  of  having  once  ineffectually  tried  to  pass 
a  chain-saw  around  the  neck  of  a  thigh  bone,  we  depend 
entirely  upon  observation  of  cases  concerning  which  we 
have  been  consulted  by  other  surgeons,  and  the  published 
results  of  osteotomy  treatment. 

All  surgeons  do  not  speak  of  osteotomy  for  in-knee  with 
equal  couleur  de  rose.     Mikulicz  (op.  cit.,  p.  758)  acknow- 

*  Holmes  :  '  System  of  Surgery,'  2ncT  edition  ;  article,  "  Orthopaedic 
Surgery." 

f  L.  S.  Little :  '  Med.  Cliir.  Trans.,'  vol.  54,  1871. 


142  IN-KNEE    DISTORTION. 

ledges  relapses  after  it,  whether  or  no  actual  rachitic  soft- 
ening or  disease  elsewhere  existed,  and  speaks  of  the 
necessity  of  precautionary  irons  to  be  worn  for  some 
months  afterwards.  It  is  certain  that  no  justification  for 
osteotomy  can  be  found  in  cases  in  which  the  softened  stage 
of  rickety  bones  actually  exists.  In  the  second  half  of 
Mikulicz's  list  of  cases  of  osteotomy  for  in-knee,  the  treat- 
ment occupied  from  seven  to  ten  weeks. 

We  have  already  admitted  the  necessity  for  osteotomy 
with  considerable  bone  curvature  during  adolescence  when 
they  have  become  eburnated,  and  when  from  the  extent  of 
the  curvature  the  weight  of  the  trunk  to  be  borne  by  the 
limbs  tends  to  augment  the  curvature  of  even  the  eburnated 
bones,  and  to  cause  displacement  of  the  knee  (genu-valgum) 
and  of  the  ankle  (flat-foot). 

We  know  not  to  what  extent  the  opinion,  that  it  is 
desirable  in  young  children  to  avoid,  if  possihle,  any  con- 
siderable surgical  operation,  is  in  unison  with  that  of  the 
majority  of  operating  surgeons.  It  is  well  known  that 
infants  are  almost  unconscious  of  an  operation  being  done, 
and  the  use  of  anaesthetics  in  older  children  has  entirely 
removed  the  pain  of  an  operation  from  amongst  the 
objections  to  it.  But  there  are  many  children  who,  with 
high  order  of  intelligence,  combine  a  morbid  sensibility  to 
mental  impressions,  which  re-acts  badly  upon  the  system  at 
large,  and  which,  added  to  the  disadvantage  of  entire  con- 
finement for  several  weeks,  favours  the  development  of 
neurosis  and  disorders  of  nutrition,  which  it  is  most  de- 
sirable to  avoid.  We  write  in  this  spirit  of  caution  as  to 
osteotomy  operations,  for  the  same  reason  as  we  have 
written  against  unnecessary  tenotomy. 

We  may  take  as  a  type  of  less  successful  osteotomy  of 
the  tibia  the  comparatively  recent  experience  of  Billroth,* 
who   lost   two   patients   out   of  thirteen   by   "  sepsis   and 

■'•  0]3.  cit. 


WHEN    OSTEOTOMY    IS    DESIRABLE.  143 

pyemia."  If  all  the  surgeons  who  have  practised  osteotomy 
in  this  country  published  their  unsuccessful  cases,  as  well 
as  their  successful  ones,  it  would  be  easier  to  determine  the 
exact  risk  which  would  be  incurred  by  exchanging  the  slower 
mechanical  treatment  of  severe  genu-valgum  in  adolescents 
and  adults  for  the  more  rapid  proceeding  of  osteotomy. 

The  success  which  has  been  attained  by  Macewen  ought 
surely  to  accompany  subsequent  surgeons.  At  the  same 
time  we  would  remark  that  the  knowledge  that  living  ortho- 
paedic physicians  and  surgeons  have  restored  hundreds  of 
adolescent  and  some  adult  in-knees  without  operation  or 
violence;*  and  that  Mikulicz  t  mentions  "that  in  severe 
rachitis  the  bones  offer  less  resistance  during  osteotomy  to 
the  chisel  and  mallet "  than  healthy  bones, — a  fact  indirectly 
testified  to  by  Macewen,  who  mentions  that  after  having 
divided  with  the  chisel  the  larger  portion  of  the  femur  the 
remaining  portion  yields,  after  the  manner  of  a  green-stick 
fracture  of  a  rickety  bone,  by  the  application  of  the  surgeon's 
hands  to  it  with  the  view  of  straightening  the  limb, — raises 
the  presumption  that  many  of  the  cases  which  have  been 
cured  by  the  aid  of  osteotomy  would  have  recovered 
without  it. 

We  have  shown  in  these  pages  that  the  larger  propor- 
tion of  in-knee  cases  are  in  their  early  stages  unconnected 
with  curvature  of  bones,  and  are  not,  in  our  opinion,  of 
rickety  origin,  and  that  in-knee  is  essentially  a  distortion 
of  the  joint.  In  deciding  on  the  advantage  of  recourse  to 
osteotomy,  we  should  separate  the  question  of  in-knee  from 
that  of  curvature  of  the  leg  bones.  The  reader  has  seen 
(p.  46)  that  Mayer,  who  first  performed  osteotomy  for  in-knee, 
severed  the  tibia,  and  removed  a  wedge-shaped  portion  of 
that  bone.    His  example  was  largely  followed.    He  appears 

*  See   Gueriu,    also   Little :     '  Trans,    of  tlie    International    Med. 
Congress,'  vol.  iv.,  London,  1881. 
f  Op.  cit.,  p.  623. 


144  IN-KNEE   DISTORTION. 

to  have  overlooked  the  fact  that  in-knee,  in  the  majority  of 
cases,  results  from  disturbance  of  relation  of  parts  of  the 
joint  itself.  He  evidently  looked  upon  knock-knee  as  a 
crooked  limb,  and  straightened  it  much  as  a  joiner  might 
straighten  a  crooked  piece  of  furniture,  by  cutting  out  a 
piece  of  it.  A  glance  at  Mayer's  drawing  (fig.  16,  p.  46,  in 
this  work)  will  show,  when  compared  with  our  diagram 
(p.  27,  and  figs.  48  and  49),  how  completely  surgical  atten- 
tion to  the  joint  will  straighten  the  knee,  and  permit  Nature 
to  restore  the  balance  in  size  between  the  external  and  in- 
ternal condyles. 

The  mixing  up  of  the  fact  of  frequent  co-existence  of 
curvature  of  the  leg  bones,  with  the  fact  of  in-knee  joint 
distortion,  combined  with  the  knowledge  that  undue  hard- 
ness of  the  curved  leg  bones  is  after  a  certain  age  irre- 
movable by  instrumental  treatment,  has  given  an  undue 
impulse  to  recourse  to  osteotomy  for  in-knee,  instead  of 
causing  the  osteotomy  to  be  restricted  to  the  cure  of  the 
curvature.  It  is  worthy  of  mention  that  when  we  assisted 
at  a  double  osteotomy  operation  for  considerable  curvatm'es 
of  the  legs,  in  which  slight  genu-valgum  co-existed,  we 
observed  that  it  was  not  until  the  fibula  was  severed  that 
the  knee-distortion  disappeared. 

As  Macewen  has  stated  (oj).  cit.),  it  is  impossible  to  lay 
down  a  hard-and-fast  line  as  to  the  cases  in  which  osteotomy 
should  be  performed.  We  regard  supra-condylar  osteotomy, 
as  compared  with  "  brisement  force,"  as  the  least  violent 
method,  and  less  liable  to  be  followed  by  mischievous  con- 
sequences to  the  knee  joint. 

We  consider  that  in  childhood  osteotomy  for  uncompli- 
cated in-knee  is  never  necessary  or  justifiable.  During 
adolescence  there  are  many  cases  of  great  inversion  and 
distortion,  in  which  the  articular  structures  are  still  suffi- 
ciently yielding  to  permit  comparatively  prompt  restoration 
by  instrumental  means.     When  in  adolescents,  however, 


WHEN    OSTEOTOMY   IS    DESIEABLE.  145 

the  peculiar  curve  in  the  femur,  described  by  Linhart, 
Mikulicz,  and  Macewen,  is  very  obvious,  when  the  case  has 
been  long  neglected,  when  the  elasticity  of  the  structures 
is  lost,  and  the  impairment  of  size  of  the  external  condyle 
and  opposite  articulating  surface  of  the  tibia  is  considerable ; 
when  the  patella,  moreover,  has  abandoned  its  natural 
groove  between  the  condyles, — Macewen's  operation  may 
be  regarded  as  indispensable. 

Even  in  young  boys  we  have  found  difficulty  in  main- 
taining the  patella  in  position  when  it  has  been  temporarily 
replaced.  We  have  found  the  disposition  to  displacement 
subside  after  long-continued  instrumentation.  This  dis- 
placement is  a  strong  proof  of  great  deficiency  of  the 
external  condyle,  a  deficiency  which  may  be  felt  by  one 
hand  of  the  surgeon,  whilst  he  holds  the  patella  in  its 
proper  place  with  the  other  hand.  Kemembering  the  con- 
cern such  cases  have  afforded  us  we  should  regard  this 
state  of  the  patella  as  a  powerful  contributory  reason  for 
osteotomy  when  difficulty  is  experienced  in  keeping  it  in 
position,  so  long  as  the  patient  is  permitted  to  take 
exercise. 

Osteotomy  becomes,  then,  the  complement  to  mechanical 
treatment ;  and  it  will  strike  the  reader  who  has  followed 
the  author's  description  of  the  physical  obstacle  to  cure 
afforded  by  the  deterioration  of  the  outer  half  of  the  articu- 
lating knee  surfaces,  that  correct  instrumental  treatment 
and  supra-condylar  osteotomy  work  towards  cure  in  the 
same  groove  as  regards  "  indication"  of  treatment. 

In  the  rachitic  cases  termed  genu-valgum,  but  in  which 
considerable  curvature  of  thigh  and  leg  bones  has  more  to 
do  with  the  distortion  than  any  changes  in  the  knee  joint, 
after  the  age  of  eight  or  ten  years,  when  instrumental 
treatment  can  effect  little  improvement  in  the  curvatures, 
osteotomy  can  alone  be  relied  on.  It  should,  however, 
be   remembered  that  a  moderate   amount   of  permanent 

u 


146  IN-KNEE    DISTORTION. 

curvature  of  thigh  and  leg  bones  is  not  incompatible  with 
effective  use  in  after  life. 

The  treatment  of  out-knee  curvature  of  legs  and  thighs, 
fig.  6  (genu- varum),  requires  to  be  conducted  on  the  same 
principles  as  in-knee,  but  they  should  be  reversed  in  the 
mode  of  application.  Such  "bow-legs,"  when  severe,  are 
less  easy  to  manage  than  severe  in-knee. 

It  cannot  be  too  strongly  inculcated  upon  the  young 
surgeon  that  the  object  of  treatment  for  the  removal  of 
many  deformities  should  be  less  for  the  improvement  of 
form  than  for  the  restoration  of  perfect  function. 


ON  THE  OPEEATION  OF  OSTEOTOMY. 


Osteotomy,  for  the  cure  of  distortions,  has  traversed  a 
path  similar  to  that  of  tenotomy,  in  having  at  first  been 
performed  by  large  open  incisions,  the  structures  in  the 
vicinity  of  the  divided  bone  being  much  disturbed  by  the 
movements  of  the  saw,  the  operation  being  usually  followed 
by  severe  constitutional  disturbance,  suppuration,  and  often 
by  death.  The  pioneer  in  this  operation  was  A.  Mayer,  who, 
in  1852,  published  a  valuable  paper  on  the  subject.  He 
appears  to  have  first  performed  osteotomy  ten  years  before 
the  appearance  of  this  publication.*  So  long  ago  as  1836 
the  author  witnessed  removal  of  a  "hammer-toe"  by  Dief- 
fenbach,  in  Berlin,  with  one  touch  of  a  chisel  and  mallet, 
without  preliminary  incision  of  the  integuments.  Langen- 
beck  (1854),  Pancoast  (1859)  and  Grosse  (1861)  in  America, 
L.  Stromeyer  Little  (1865),  Billrotht  in  Germany,  and  W. 
Adams  (1869)  in  this  country,  have  been  the  foremost,  in 
point  of  time,  in  the  employment  of  osteotomy  for  the  treat- 
ment of  ankylosis  and  distortions  of  bones. 

It  is  of  historical  and  therapeutic  interest  that  in 
A.  Mayer's  first  case — despite  the  making  of  a  flap  of  skin 
over  the  head  of  the  tibia  half  the  width  of  the  leg,  and 
sawing  with  a  Heine  saw,  and  removal  of  a  wedge  of  bone, 
the  wound  having  being  washed  out  with  cold  water  to 

*  A.  Mayer:  '  Illtistrirte  Medicinische  Zeitung,'  July,  1852. 
f  Ueber  die  Verwendung  vom  Bildhauermeissel  bei  Osteotomieen, 
'  Wiener  Med.  Wochenschrift,'  1870. 


148  IN-KNEE    DISTOKTION. 

remove  "the  sawdust" — the  wound  healed  in  six  days,  and 
the  union  of  the  bone  was  firm  after  twenty-four  days. 
After  recovery  from  the  operation  on  the  first  hmb,  he 
operated  the  second  Hmb.  It  was  a  disastrous  operation, 
through  his  having  divided  the  posterior  tibial  artery,  nerve 
and  veins.  After  many  "  accidents"  the  patient  died  from 
tetanus  on  the  sixty-second  day.  In  his  fourth  case,  through 
breaking  the  chain  of  the  saw,  he  found  himself  obliged  to 
have  recourse  to  two  chisels  from  his  dissecting  case .'  These, 
doubtless,  were  not  previously  cleansed  with  carbolic  acid 
solution,  but  by  inserting  them  as  deeply  as  possible  in  the 
groove  already  made  in  the  bone  he  succeeded  by  main 
force  in  sundering  the  "  very  firmly  resisting  bone."  Despite 
six  months'  of  suppuration,  bed-sores,  &c.,  the  patient  wholly 
recovered. 

These  first  efforts  of  Mayer  were  not  encouraging  to 
others  engaged  in  the  treatment  of  distortions,  especially 
to  those  who  had  constantly  succeeded  in  rectifying  even 
the  severest  in-knee  by  instrumental  means. 

The  surgeons  who  first  followed  in  the  steps  of  Mayer  in 
regard  to  osteotomy,  especially  the  American  surgeons, 
followed  rather  the  example  set  them  by  Ehea  Barton  in 
1826,  whom  we  have  cited,  and  mostly  directed  their  atten- 
tion to  hip  ankylosis. 

In  1875  Annandale  severed  the  internal  condyle  of  the 
femur  for  genu-valgum,  with  the  disadvantages  of  opening 
the  joint  and  severing  all  the  ligaments ;  but  he  found  few 
imitators.  Ogston's  operation  was  an  improvement  upon 
Annandale' s.* 

In  later  times  BiHroth  adopted  the  more  subcutaneous 
method  of  osteotomy  by  chisel  and  mallet,  and  in  1872 
applied  it  to  in-knee  and  out-knee,  following  the  example 
of  Lister  in  improved  attention  to  wound  dressing.     In 

*  See  a  valuable  lecture  on  this  siahject,  by  Mr.  Barker,  in  tbe 
Brit.  Med.  Journal,'  July,  1879. 


ORIGIN  OF  "  SUBCUTANEOUS  "  OSTEOTOMY.       149 

1878  Billroth  first  performed  supra-condylar  osteotomy  on 
the  femur  for  in-knee. 

We  claim,  however,  for  Mr.  L.  Stromeyer  Little  the 
merit  of  having  first  applied  (in  1868)  Stromeyer's  principle 
of  subcutaneous  tenotomy  to  division  of  bone,  as  nearly  as 
it  is  possible  to  apply  it.  The  case  was  one  of  osseous 
union  of  the  knee  joint ;  the  separation  of  the  adherent 
bones  was  effected  by  a  ^  inch  wide  chisel  and  a  mallet,  the 
aperture  in  the  integuments  had  only  the  size  of  the  narrow 
chisel  used,  the  wound  was  covered  with  a  piece  of  lint 
only,  and  the  limb  bandaged,  as  in  the  case  of  a  tenotomy 
wound.  Cicatrisation  occurred  in  six  days  without  sup- 
puration or  other  difficulty.  Listerism  may  be  said  to  have 
revolutionised  the  treatment  of  open  wounds,  but  it  has 
done  nothing  for  subcutaneous  tenotomy,  as  the  minute 
punctures  of  this  operation  have  invariably  healed  in 
thousands  of  cases  within  forty-eight  or  seventy-two  hours, 
without  trace  of  suppuration.  As  there  is  only  a  quasi- 
punctured  wound  in  chisel  osteotomy,  there  is  no  reason 
for  Listerism. 

We  have  seen  that  Macewen  in  supra-condylar  osteo- 
tomy, and  W.  Adams  in  his  division  of  the  neck  of  the 
femur  with  the  saw,  find  it  sufficient  merely  to  place  a 
piece  of  carbolised  or  plain  lint  over  the  "  subcutaneous  " 
puncture-like  wound.  In  cases  where  considerable  detritus 
of  bone  has  been  left  behind  by  the  saw  it  becomes  absorbed, 
as  we  have  seen  in  several  cases. 

Many  surgeons,  who  were  insufficiently  acquainted  with 
the  writings  of  their  predecessors  on  the  pathology  and 
morbid  anatomy  of  in-knee,  having  observed  the  undue 
prominence  of  the  internal  condyle,  regarded  this  symptom 
as  the  pathognomonic  one,  and  followed  one  another  in 
their  attack  upon  this  part.  They  were  not  deterred  by 
any  apprehension  as  to  opening  the  knee  joint,  and  more 
than  one  surgeon  freely  exposed  it.     It  is  not  known  what 


150  IN-KNEE    DISTORTION. 

percentage  of  loss  of  limb  or  of  life  has  attended  this 
method  of  treatment. 

In  regard  to  it  Mikulicz  (oj;.  cit.,  p.  764)  considers  it  an 
error  to  regard  the  internal  condyle  as  the  essence  of  the 
complaint,  and  shows  that  by  detaching  the  internal  con- 
dyle, and  its  removal  upwards,  an  incongruence  is  estab- 
lished between  the  articular  surfaces  of  the  femur  and  tibia, 
and,  as  a  consequence  of  it,  an  impairment  of  the  subsequent 
mobility  of  the  joint.  He  avers  that  after  sawing  off  the 
condyle  much  force  was  required  to  straighten  the  limb. 

In  this  laudable  march  of  modern  surgery  in  search  of 
a  successful  mode  of  treating  the  cases  believed  to  be  inve- 
terate, we  are  of  opinion  that  old-fashioned  ideas  of  the 
supposed  influence  of  primitive  malformation  of  bones  have 
had  as  much  mischievous  influence  in  regard  to  the  inver- 
sion of  the  knee  joint  (genu- valgum)  as  they  have  had  in 
relation  to  supposed  inveterate  congenital  club-foot. 

Having  assumed  the  accuracy  of  statements  of  many 
old  observers  of  distortions,  who  in  their  ignorance  of  the 
links  in  the  chain  of  causation  of  distortions  met  with  in 
the  embryo,  the  foetus,  and  the  infant,  and  seen  to  originate 
in  childhood,  and  even  after  adult  age,*  surgeons  have  too 
readily  employed  the  knife,  the  saw,  and  the  gouge  to  re- 
move or  reduce  that  bony  matter  which  appeared  beyond 
the  reach  of  milder  measures ;  errors  here,  as  elsewhere, 
having  begotten  further  error.  Osteotomy,  for  the  relief 
of  bent  bones  and  of  ankylosis,  has  rested  upon  surer 
indications. 

We  have  endeavoured  in  that  which  we  have  written  in 
the  previous  pages  to  bring  before  the  reader  all  the  facts 
known  to  us  in  the  symptomatology,  pathology,  and  morbid 
anatomy  of  in-knee,  furnished  by  others  or  observed  by 
ourselves,  the  result  of  such  research  being  to  show  that 

■'■  8ee  paper  on  etiology  of  club-foot,  in  '  Trans,  of  Internat.  Med. 
Cong.'  Lontl.,  1881. 


OSTEOTOMY.  151 

in  treating  knee  joint  inversion  we  have  to  concentrate  our 
attention  more  upon  the  external  condyle,  as  compared 
with  the  internal  one,  and  primarily  to  endeavour  to  better 
the  condition  of  the  external  condyle,  or  of  the  external  side 
of  the  joint,  rather  than  of  the  internal  side. 

We  are  addressing  a  younger  generation  whose  duty,  as 
regards  this  distortion,  is  the  cure  of  it  in  its  earliest  stage, 
and  that  of  preventing  it  from  attaining  the  inveterate 
stage,  which  can  alone  ever  justly  become  the  subject  of 
operation  of  any  kind. 

Macewen  {op.  cit.)  regards  the  numerous  cases  which  he 
has  operated  as  being  due  to  curvature  of  the  femur  at  its 
lower  portion  (see  p.  41) ;  but  he  also  shows  that  he  has  in 
many  cases  been  compelled  to  divide  the  leg  bones  on 
account  of  curvature  of  them.  Many  of  his  cases,  therefore, 
were  rachitic  curvatures  of  the  thigh  and  leg  bones,  and 
not  cases  of  in-knee,  i.  e.,  abnormal  knee  joint  inclination 
inwards,  through  change  of  relation  and  form  of  the  parts 
proper  to  the  articulation.  Those  in  which  he  did  not  find 
it  necessary  to  divide  the  leg  bones,  as  well  as  the  femur, 
were  probably  non-rachitic. 

Having  reviewed  a  large  number  of  cases  operated  by 
•different  surgeons,  we  have  noticed  the  fact  that  in  several 
instances,  when  both  limbs  were  considered  to  require 
osteotomy,  the  operation  on  the  second  limb  was  postponed 
until  recovery  had  taken  place  from  the  first  operation.  In 
several  instances  of  death  the  fatality  occurred  after  the 
second  operation.  We  think  it  probable  that,  barring  un- 
avoidable accidents,  the  patient  who  has  been  confined  to 
the  house  or  hospital  several  weeks  is,  as  regards  his 
physical  condition,  a  less  favourable  subject  than  he  was  at 
the  time  of  operation  of  the  first  limb.  This  is  still  more 
likely  to  be  the  case,  despite  the  encouragement  afforded 
by  the  success  of  the  first  operation,  as  regards  the  morale. 

A  five  or  six  weeks'  confinement  within  doors,  passed  in 


152  IN-KNEE    DISTORTION. 

bed  or  without  exercise,  an  average  good  diet  being  used, 
notwithstanding  the  best  watchfuhiess  of  the  surgeon,  is 
not  a  good  preparation  for  an  osteotomy  of  thigh  or  leg, 
even  when  most  skilfully  performed  under  subcutaneous 
and  antiseptic  conditions,  and  reduced,  as  Macewen  con- 
siders the  surgical  breach  of  continuity  to  be,  from  the 
rank  of  a  compound  fracture  to  that  of  a  simple  one. 

It  cannot  be  doubted  that  in  a  constitution  in  which 
any  latent  tendency  to  disturbance  or  disease  of  any  of  the 
internal  organs,  or  system  of  organs,  exists,  a  few  weeks' 
confinement  and  deprivation  of  exercise  after  an  operation, 
even  if  no  great  constitutional  disturbance  has  been  caused 
by  the  operation,  may  favour  the  outbreak  of  symptoms 
which  may  jeopardise  its  success,  and  even  the  patient's 
life.  We  have  twice  known  a  patient  confined  for  five  or 
six  weeks,  through  so  simple  a  matter  as  a  fractured  patella, 
die  suddenly  from  heart  disease,  of  which  the  existence  had 
not  been  surmised  by  the  friends  or  the  medical  attendant. 

We  consider,  therefore,  that  Macewen  was  right  in 
theory  when  he  first  undertook  the  performance  of  double 
and  multiple  subcutaneous  osteotomy  at  the  same  time, 
and  his  experience  has  fully  justified  the  proceeding. 

It  is  unnecessary  to  review  here  the  several  methods  of 
severing  the  thigh  bone  for  severe  in-knee,  or  the  leg  bones 
when  curvature  of  these  complicates  the  knee  distortion,  or 
has  become  the  main  deformity,  which  has  been  carried 
out  by  Annandale,  Ogston,  Barwell,  Reeves,  and  others,  for, 
in  our  opinion,  the  method  pursued  by  Macewen  is  destined 
to  supplant  them  all  by  its  simplicity,  celerity  of  perform- 
ance, safety,  and,  moreover,  by  the  perfection  of  its  results. 
We  have  not  only  carefully  perused  all  that  this  surgeon 
has  written  on  the  subject,  but  have  had  the  opportunity, 
afforded  by  him,  of  witnessing  his  performance  of  a 
double  operation,  at  a  private  clinical  seance  at  Glasgow, 
and  of  thoroughly  examining  several  adolescent  patients, 


macewen's  opeeation.  153 

and  an  adult,  who  had  been  operated  on  some  months,  and  in 
one  case  two  years  previously.  Even  in  the  adult,  who  had 
been  one  of  the  most  seriously  affected,  practised  eyes  and 
hands  failed  to  discover  more  than  the  faintest  sign  that 
in-knee  had  ever  existed. 

In  judging  of  the  amount  of  spontaneous  restoration 
and  cure  of  in-knee  through  renewal  of  growth  of  the  ex- 
ternal condyle  and  opposite  part  of  the  tibia,  as  well  as 
through  arrest  of  undue  growth  of  the  internal  condyle  and 
its  corresponding  articular  surface  of  the  tibia,  we  refer  the 
reader  not  only  to  the  diagram  a,  figs.  20,  21,  49  and 
51,  but  also  to  the  observations  respecting  the  normal  pro- 
portions of  these  parts  contained  on  page  22  et  seq.  Prom 
these  it  will  be  apparent  that  the  degree  of  obliquity  of  the 
articular  surfaces  engendered  by  even  so  slight  an  excess 
in  length  of  the  internal  over  the  external  condyle,  as  may 
be  compensated  by  three  bronze  pennies  (fig.  9  d,  page  23) 
placed  beneath  the  latter,  would  suJSice  to  allow  of  a  not 
unimportant  in-knee  distortion.  A  very  slight  deficiency 
in  one  part  and  excess  in  the  other  will  suffice  to  account 
for  the  amount  of  in-knee  shown  in  figs.  11  and  12.  Such 
cases  readily  yield,  as  we  have  sufficiently  said,  to  mecha- 
nical treatment. 

It  is  only  in  cases  of  very  considerable  disparity  in  the 
length  of  the  two  condyles,  as  at  figs.  14,  30,  and  50,  that  a 
large  amount  of  letting  down  of  the  external  condyle  by 
supra-condylar  osteotomy  would  be  required.  In  this  case 
the  gap  to  be  filled  up  by  callus  might  be  as  great  as  that 
represented  at  fig.  51. 

Dr.  Macewen  objects  to  the  use  of  the  word  chisel,  which 
he  says  conveys  an  erroneous  idea  of  his  instrument,  which  he 
prefers  to  call  an  osteotome.  It  is  of  tempered  steel,  handle 
and  blade  being  one  piece,  and,  strictly  speaking,  has  no 
bevel,  the  straight  line  of  either  side  of  the  blade  being 
continued  right  up  to  the  cutting  edge,  and  a  long  and 

X 


154  IN-KNEE    DISTORTION. 

taper  wedge  is  thus  formed.  He  advocates  antiseptic  pre- 
cautions, and  the  use  of  the  bloodless  method  of  Esmarch 
and  of  Listerism.  The  operation  is  thus  performed  : — The 
limb  is  laid  on  its  outer  side  on  a  pillow  of  damp  sand,  and  a 
longitudinal  incision  of  sufficient  width  is  made  with  a 
scalpel,  "at  a  point  where  the  two  following  lines  meet, — 
one  drawn  transversely  a  finger  breadth  above  the  superior 
tip  of  the  external  condj^le,  and  a  longitudinal  one  drawn 
half  an  inch  in  front  of  the  adductor  magnus  tendon." 
The  osteotome  is  to  be  passed  down  to  the  bone  by  the  side 
of  the  scalpel,  which  is  then  withdrawn,  and  the  former 
is  turned  into  a  transverse  position,  and  made  to  pene- 
trate the  bone  by  successive  blows  with  a  mallet,  being 
directed  slightly  forwards  in  order  to  avoid  the  femoral 
artery.  Care  must  be  taken  to  avoid  impaction  of  the 
osteotome  ;  and  if  the  bone  be  very  thick  two  or  three  instru- 
ments may  be  used,  each  more  slender  than  its  predecessor. 
The  compact  layer  on  the  outer  aspect  of  the  limb  need  not  be 
divided,  as  it  yields  easily  on  applying  straightening  force  to 
the  leg.  The  limb  is  then  placed  in  a  suitable  splint,  and  the 
dressings,  if  all  goes  well,  are  not  removed  for  a  fortnight. 
Union  is  usually  firm  after  six  weeks,  when  the  splints  are  re- 
moved, and  the  patient  shortly  afterwards  is  allowed  to  w^alk 
with  crutches.  Dr.  Macewen  states  that,  as  a  rule,  ten  weeks 
elapse  from  the  operation  till  the  time  when  the  patient  can 
walk  about  freely,  and  without  artificial  support. 

We  have  here  described  the  leading  points  in  Macewen's 
proceeding.  Simple  as  they  are,  we  strongly  advise  every 
surgeon,  about  to  operate  by  this  method  for  the  first  time, 
to  study  all  the  minor  points  insisted  upon  by  him ;  *  for 
here,  as  elsewhere  the  great  Wellington  said,  victory  when 
traceable  to  the  leader  has  depended  upon  attention  to  the 
smallest  details. 

Great  as  has  been  Macewen's  success  we  venture  to 

*  Macewen:  'Osteotomy,'  London,  1880. 


MACEWEN  S    OPERATION. 


155 


Fig.  50. 


differ  with  him  in  the  explanation  of  the  nature  of  the 
subsequent  physical  changes  effected  in  the  femur  and  in 
the  knee  joint  by  his  mode  of  operation. 

Annexed  is  a  representation  (fig.  50)  of  a  thigh  bone 
from  a  genu-valgum  case,  from  Macewen's  work.  We  may 
remark  that  we  have  never  met  with  so  pronounced  a  pro- 
longation of  the  internal  condyle  with  so  little  apparent  dete- 
rioration of  the  external  one.  The  annexed  figure  represents 
the  left  femur.  After  having  driven 
the  thin,  but  wedge-like  chisel  two- 
thirds  or  three-fourths  of  the  distance 
through  the  lower  end  of  the  shaft  of 
the  bone,  he  removes  it,  having  un- 
avoidably made  a  gap  on  the  inside 
of  the  bone  of  at  least  the  thickness 
of  the  substance  of  the  chisel.  He 
then  completes  the  division  of  the 
bone  by  fracturing  the  undivided 
portion  whilst  in  the  act  of  forcibly 
adducting  the  limb  with  his  hands. 

The  gap  formed  by  the  chisel  on  the     Front  vieio  of  the  condylar 

inside,  caused  by  its  increasing  thick- 
ness as  it  is  driven  towards  the  ex- 
ternal side,  driving  upwards  and 
downwards  the  resisting  bone  sub- 
stance, is  of  service,  as  far  as  it  goes, 
in  diminishing  the  length  of  the  in- 
ternal condylar  part  of  the  bone,  and,  pro  tanto,  favouring 
some  degree  of  elevation  of  the  internal  condyle.  We  are  of 
opinion,  however,  that  when  the  external  part  of  the  femur  is 
fractured  in  the  act  of  forcibly  straightening  the  limb  (and  we 
have  observed  that  very  slight  force  is  needed  for  the  purpose, 
owing  to  the  length  of  leverage  which  the  foot  and  leg  afford) 
a  considerable  gap  on  the  external  side  is  formed,  as  repre- 
sented by  us  at  fig.  51.     This  therapeutic  gap  in  the  femur, 


end  of  left  femur  before 
osteotomy,  from  Mace^oen, 
p.  135 ;  hut  -placed  by  its 
in  the  direction  the  thigh 
bone  iDould  assume  in 
tolerably  severe  in-knee. 
Probably  a  rickety  ease. 


156 


IN-KNEE    DISTORTION. 


Fig.  51. 


destined  to  be  filled  up  by  callus,  represents  a  substitute  for 
the  gap  in  the  infant's  leg  shown  by  us  in  diagram  a,  p.  27, 
and  which  is  formed  whenever  the  surgeon,  by  the  manoeuvre 
there  described,  straightens  the  infant's  early  stage  of  in- 
knee.  The  therapeutic  gap  above  the  external  condyle, 
resulting,  we  believe,  from  Macewen's  method  of  operating, 
lets  down  the  external  condj'le  to  its  proper  level,  and  when 
filled  up  by  the  callus  supplies  the 
deficiency  in  its  length,  found  to  exist 
by  many  observers  as  a  consequence 
of  previous  absorption  through  undue 
compression  and  attrition.  The  filling 
up  of  this  gap  by  callus  has  the  advan- 
tage of  preventing  any  loss  of  length 
of  the  limb  through  the  osteotomy. 

We  consider  that  if  Macewen's 
figure  (28)  and  explanation,  p.  134 
(op.  cit.),  be  correct,  then  his  handi- 
work with  the  chisel  at  the  point  of 
entry  into  the  bone  on  the  inner  side, 
whether  it  be  used  as  it  advances  as 
a  lever  to  press  sufficiently  aside  the 
sides  of  the  severed  internal  parts  of 
the  bone,  or  aided  by  the  mallet 
as  a  chipping  instrument,  which  we 
know  in  Macewen's  hands  it  is  not,  so  as  to  leave  almost 
only  a  linear  space  between  the  severed  parts  instead  of 
the  larger  triangular  space  on  the  outside  here  repre- 
sented, the  femur  must  be  proportionately  shortened  on 
the  inside  by  such  a  process.  If  Macewen's  explanation  be 
applicable,  it  can  only  be  in  those  cases  of  young  chil- 
dren, whom  he  admits  having  operated  on,  in  whom 
the  bones  were  soft  and  compressible.  In  eburnated  bones 
of  rachitic  subjects  especially,  which  evince  extraordinary 
and  fatiguing   resistance  to  the  saw,  and  in  adult  bones 


The  femur  represented  im- 
mediately after  osteo- 
tomy, by  Maceicen's  me- 
thod, according  to  our 
ex2}erience,  ichich  differs 
in  this  resi^ect  from  that 
of  Dr.  Macewen. 


macewen's  operation.  157 

of  normal  hardness  of  atonic  or  idiopathic  in-knee  sub- 
jects, the  bones  will  not  permit  the  crushing  aside  by 
the  chisel-osteotome.  They  are  more  disposed  to  split ; 
and  it  seems  to  us  probable  that  when  the  surgeon,  after 
chiselling  through  two-thirds  of  the  bone,  or  more,  has 
straightened  a  limb  without  the  production  of  the  sound  of 
the  remainder  having  snapped  apart,  it  has,  in  the  hard  adult 
or  eburnated  bone  of  the  rachitic  subject,  resulted  from  its 
having  been  cracked  by  the  chisel  through  the  remainder  of 
the  distance  to  be  severed,  and  thus  the  limb  could  be 
straightened  without  resistance,  rather  than  that  the  yield- 
ing was  due  to  bending  in  such  cases.  We  consider  that 
Dr.  Macewen's  section  of  the  femur,  made  by  him  for  sound 
reasons,  from  the  inner  aspect  of  the  bone,  leaves  it,  as 
regards  the  gap  to  be  filled  up,  in  nearly  the  same  condition 
as  if  he  divided  it  from  the  outer  side. 

In  fig.  50  the  disparity  in  length  of  the  two  condyles  is 
greater  than  we  remember  to  have  ever  actually  seen,  but 
this  disparity  in  all  cases  of  knock-knee  is  determined  and 
gradually  augmented  by  the  gradually  increasing  inward 
inclination  of  the  knee.  In  short,  the  changes  in  size  and 
form  of  the  internal  condyle  is  not  an  original  malformation, 
but  one  resulting  from  the  action  of  gravity  and  of  the 
muscles,  the  latter  being  the  agents  in  some  rare  eases  of 
foetal  origin. 

We  have  been  informed  of  a  case  in  which  a  surgeon, 
whilst  performing  the  supra-condylar  operation,  had  the 
misfortune  to  split  the  femur  longitudinally.  This  accident 
could  never  happen  in  the  softened  bone  of  the  child ;  ergo, 
anyone  unskilled  in  the  use  of  the  chisel  should  only 
attempt  division  in  the  young,  because  their  bones  are  apt 
not  to  have  become  eburnated.  We  have,  however,  said 
sufficient  in  the  former  pages  against  the  practice  of  per- 
forming osteotomy  at  all  in  young  children,  for  one  of  the 
best  of  reasons  that  their  bent  knees  and  bones   easily 


158  IN-KNEK    DISTORTION. 

permit  straightening  b}^  gentle,  painless,  prompt,  and  safe 
mechanical  means.  Even  in  adolescents  osteotomj^  is,  in 
our  opinion,  unjustiliable,  unless  adequate  skilful  instru- 
mentalism  has  been  tried  in  vain. 

The  experience  derived  from  the  use  of  instrumental 
treatment  and  from  osteotomy  leads  to  the  conclusion  that 
the  solidification  of  the  bones  of  a  rachitic  subject,  the 
beginning  of  which  is  very  evident  at  about  the  age  of  five 
or  seven  years  and  marks  the  cessation  of  rachitic  disease, 
differs  materially  in  hardness  and  density  from  that  per- 
fect ivory  hardness  and  full  eburnation  which  characterises 
the  bones  of  a  rachitic  adult,  in  which  the  labour  of  sawing 
a  femur  or  tibia  asunder  is  an  arduous  one.  For  the  same 
reason  chisel  osteotomj^  in  the  adult  is  more  difficult  than 
in  the  growing  child  or  adolescent.  A  firm  grasp  of  the 
chisel-osteotome  by  the  surgeon  is  necessary  ;  at  the  same 
time  his  fingers  need  to  feel  every  movement  of  the  imple- 
ment, as  if  they  reached  to  its  extremity  so  as  to  watch  its 
slightest  inclination  to  depart  from  the  proper  direction. 

We  go  further,  and  say  that  no  surgeon  untrained  in 
the  manual  use  of  such  "tools"  should  undertake  this 
operation.  It  is  a  piece  of  handiwork  requiring  dexterity 
such  as  many  surgeons  do  not  possess,  however  great  may 
be  their  knowledge  of  surgical  anatomy.  Macewen,  having 
done  over  800  such  osteotomies,  has  gone  through  a  long 
apprenticeship  in  his  benevolent  career  for  the  relief  of  the 
previously  neglected  population  of  a  great  manufacturing 
and  commercial  city. 

We  have  shown  (p.  16)  that  about  the  commencement  of 
puberty,  say  from  the  age  of  ten  or  twelve  to  the  fourteenth 
or  sixteenth  year,  growth  is  extraordinarily  rapid,  and  osteo- 
tomy has  not  been  tested  sufficiently  long  to  enable  us  to 
judge  of  its  efl'ect  upon  the  subsequent  growth  and  length  of 
the  limb,  particularly  when  performed  near  the  epiphysis. 
Some  may  consider  that  this  possible  impairment  of  growth 


TREATMENT  OF  CURVATURES  OF  BONE.        159 

is  of  less  importance  when  both  hmbs  are  subjected  to  opera- 
tion, or  in  the  rachitic,  who  are  predisposed  by  that  disease 
to  diminished  growth.  In  non-rachitic  in-knee,  which  occurs 
principally  in  those  destined  to  be  tall,  or  at  the  ages  when 
growth  is  most  rapid,  anything  calculated  to  interfere  with 
growth  of  bone  should,  if  practicable,  be  avoided. 

The  treatment  of  curvatures  of  the  bones  is  so  associated 
with  in-knee  deviation  that  we  may  detail  in  this  place 
our  experience  and  reflections  on  the  best  mode  of  relieving 
them,  whether  by  mechanical  or  operative  means.  In 
the  use  of  mechanical  apparatus  it  is  advisable  to  make 
direct  pressure  on  the  most  prominent  part,  when  from  the 
nature  and  form  of  the  curve  it  is  attainable  without  the  risk 
of  injuring  or  abrading  the  integument.  At  the  same  time 
counter-pressure  requires  to  be  made,  if  possible,  at  the 
upper  and  lower  ends  of  the  bone. 

Thus,  as  an  encouragement  to  the  employment  of  well- 
directed  mechanical  apparatus,*  we  showed,  in  a  former  work, 
that  the  femur  of  an  adolescent  aged  sixteen,  which  had  been 
fractured  nine  months  before,  and  had  been  suffered  through 
the  acknowledged  neglect  of  the  surgeon  to  unite  at  nearly  a 
right  angle,  presenting  forwards,  with  a  corresponding  great 
shortening  of  the  member,  had  been  rectified  in  a  few 
months.  We  recommend  in  such  a  case  double  "iron"  from 
the  i3elvis  to  the  ground,  with  a  crutch  beneath  the  tuberosity 
of  the  ischium  to  receive  much  of  the  weight  of  the  trunk 
during  any  permissible  exercise.  Direct  pressure  on  the 
protruding  angle  should  be  made  by  a  properly  shaped 
padded  metal  piece,  acting  from  before  backwards.  We 
trust  mainly  to  the  shape  of  the  head  of  the  femur  and  its 
connections  with  the  acetabalum  as  the  upper  fulcrum,  and 
upon  a  padded  metal  piece  behind  the  condyles  as  the 
lower  fulcrum. 

As  regards  osteotomy  for  the  relief  of  bone  curvatures, 

*  Little  :  '  Oii  Deformities  of  tlie  Human  Frame,'  p.  40. 


160 


IN-KNEE    DISTORTION. 


except  in  cases  of  extreme  curvature,  with  such  short- 
ening of  the  parts  on  the  concave  side  as  to  render  straight- 
ening after  simple  division  impossible,  we  regard  simple 
division  of  the  bones,  at  or  about  the  centre  of  the 
curve,  as  far  preferable  to  removal  of  a  wedge.  The 
operation  itself  is  simpler  in  the  former  case,  and  less 
serious ;  the  soft  parts  are  less  likely  to  be  damaged,  and 
no  fragments  or  chips  of  bone  liable  to  be  left  in  the  wound. 

Fig.  52. 


Diarframmatic  representation  of  {!)  a  curved  tibia,  tvithsudt.  a  luedge  as  has 
often  been  removed  for  the  purpose  of  straightening,  marked  out;  (2)  the  same, 
ioith  the  loedge  removed  and  the  bone  straightened ;  (3)  the  same,  simply 
divided  and  straightened. 

The  restoration  of  length  in  the  limb  is  far  greater  in  the 
case  of  simple  division  than  in  removal  of  a  wedge,  and  the 
small  gap  left  is  quickly  and  surely  filled  up  by  new  mate- 
rial, probably  without  greater  effort  of  nature  than  when 
theoretically  no  gap  exists.  The  accompanying  diagram 
(fig.  52)  shows  the  nature  and  amount  of  lengthening  in  a 
not  excessively  curved  tibia.     In  the  case  of  curvature  of 


OSTEOTOMY   FOR   BONE    CURVATURE.  161 

only  one  limb,  this  restitution  of  equality  in  the  length  of 
the  limbs  is  of  some  importance.  Thus  in  2,  fig.  52,  the 
line  A  B  is  increased  1*2  per  cent. ;  in  3  it  is  increased 
5'6  per  cent.  Suppose  a  tibia  14  inches  long,  curved  as 
in  the  diagram,  and  in  the  case  of  simple  division,  the 
length  of  the  limb  would  be  increased  0'78  in.,  while  in 
the  case  of  wedge  removal  it  would  only  be  improved  by 
0-16  in. 

It  is  right  to  say  that  the  many  surgeons  who,  notwith- 
standing that  their  particular  methods  of  procedure  have  not 
prevailed,  have  had  a  share  in  advancing  osteotomy  step 
by  step  from  the  bold,  yet  coarse,  sawing  method,  and  large 
cutaneous  incisions  resorted  to  by  Ehea  Barton  and  Mayer, 
to  the  almost  subcutaneous  method  employed  by  Mr.  W. 
Adams,  the  more  cutaneous  method  of  the  chisel  introduced 
for  knee  ankylosis  by  Mr.  Little,  and  the  numerous  cases  of  in- 
knee  relieved  by  that  method  by  Dr.  Macewen,  have  conferred 
a  great  blessing  upon  humanity.  The  success  of  osteotomy 
has  been  in  great  measure  due  to  the  example  of  subcutaneous 
tenotomy  set  by  Stromeyer ;  to  the  proofs  afforded  by  Jules 
Guerin  in  his  numerous  and  extensive  operations  on  living 
animals,  conducted  for  the  purpose  of  proving  the  safety 
of  applying  similarly  extensive  subcutaneous  operations  to 
man ;  to  the  teaching  of  the  bloodless  method  of  operating 
of  Esmarch  ;  and  last,  not  least,  by  the  enforcement  of  the 
value  of  antiseptic  measures  by  Lister. 


PBINTED    BY    WEST,    NEWMAN    AND    CO.,    HATTON    GARDEN, 


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